Prediction of mortality risk is important in the management of chronic heart failure (CHF). The aim of this study was to create a prediction model for 5-year cardiac death including assessment of cardiac sympathetic innervation using data from a multicenter cohort study in Japan.123I-metaiodobenzylguanidine (MIBG) imaging and whose 5-year outcomes were known were selected from this database. The late MIBG heart-to-mediastinum ratio (HMR) was used for quantification of cardiac uptake. Cox proportional hazard and logistic regression analyses were used to select appropriate variables for predicting 5-year cardiac mortality. The formula for predicting 5-year mortality was created using a logistic regression model.The original pooled database consisted of cohort studies from six sites in Japan. A total of 933 CHF patients who underwent p < 0.0001) by including HMR and its inclusion was most effective in the downward reclassification of low-risk patients. Nomograms for predicting 5-year cardiac mortality were created from the five-parameter regression model.During the 5-year follow-up, 205 patients (22 %) died of a cardiac event including heart failure death, sudden cardiac death and fatal acute myocardial infarction . Multivariate logistic analysis selected four parameters, including New York Heart Association (NYHA) functional class, age, gender and left ventricular ejection fraction, without HMR (model 1) and five parameters with the addition of HMR (model 2). The net reclassification improvement analysis for all subjects was 13.8 %  contains supplementary material, which is available to authorized users. Chronic heart failure (CHF) remains a major cause of death in current medical practice. Improving survival while maintaining good quality of life is an important goal for the medical community. With respect to diagnostic tools for assessing cardiac status, a number of clinical examinations and biochemical tests can provide information on the functional status of patients with CHF . In addi123I-metaiodobenzylguanidine (MIBG) imaging has the unique feature of visualizing sympathetic nervous function. MIBG shares pathways with noradrenaline for uptake, storage and release in sympathetic nerve endings [Among the various cardiac imaging modalities,  endings –6. Both  endings –9.Despite its documented prognostic power , MIBG imThis study focused on cardiac death and in particular the prediction of fatal cardiac events by adding information from MIBG imaging. The aims of this study were to analyze factors for predicting cardiac death and to create a prediction model incorporating MIBG imaging based on the Japanese multicenter pooled database.Individual datasets from six prospective MIBG cohort studies performed in Japan between 1990 and 2009 were combined to make a pooled database of 1,322 CHF patients as previously reported , 13–19. To create a single pooled database, cardiology specialists and/or nuclear medicine specialists in six hospitals created databases including common clinical parameters and updated the outcome in some institutions. For this study, only patients with known 5-year outcomes were included (933 patients). The demographics of this population are summarized in Table 123I-MIBG  in all institutions. To calculate a heart-to-mediastinum ratio (HMR), a whole-heart region and a mediastinal rectangular region in the upper mediastinum were drawn. Although both early and late HMRs were calculated in each institution, we used the late HMR for creating the prediction model, since late HMR showed better diagnostic accuracy than early HMR [Anterior planar images using scinticameras equipped with low-energy type collimators were obtained at 15 – 30 min (early phase) and 3 – 4 h (late phase) after injection of 111 MBq arly HMR . The meaLeft ventricular ejection fraction (LVEF) was determined using a gated blood-pool study , two-dimensional echocardiography , gated SPECT  and either a gated blood-pool study or echocardiography . The mean LVEF was 35.7 ± 13.1 % , and fatal acute myocardial infarction, was determined by the original study investigators. While clinical outcomes were confirmed from patient medical records or telephone interview in each institution, only definitely confirmed cardiac death was considered as an event. Noncardiac death was dealt with as censored at the time of death.All the clinical information and MIBG results were sent to a central institution (Kanazawa University), and were independently analyzed. Data are expressed as means ± standard deviation (SD). Contingency table analysis was examined using likelihood ratio and Pearson statistics.Variables included in the multivariate analyses were age, gender, early HMR, late HMR, MIBG washout rate, NYHA functional class, LVEF, history of diabetes, hypertension, dyslipidemia, atrial fibrillation and sustained ventricular tachycardia, and medications . B-type natriuretic peptide (BNP) was not used in the final analysis because of the limited number of patients available for analysis (299 patients). Variables derived from electrocardiography were not included in the assembled dataset.p value <0.05 was considered significant. Statistical analysis was performed using JMP 10.0.2 software , and mathematical calculation and software for creating models were based on Mathematica 9 .Multivariate Cox proportional hazard analysis was performed. Logistic regression analysis was used for single HMR and multiple variables, and receiver operating characteristic (ROC) curves and areas under the curves (AUC) were calculated. To create a prediction model, logistic models with single or multiple variables were used to calculate the cardiac mortality. Inverse prediction of HMR was also performed based on the prediction models to evaluate the threshold for low risk of mortality. Net reclassification improvement (NRI) analysis was based on the prediction models with and without HMR. The 5-year risk levels were defined as low (<5 %), intermediate (5 – 25 %) and high (>25 %). The threshold of 5 % corresponded to an accepted low-risk threshold of 1 % mortality per year. The threshold for high-risk  was chosen to exceed the approximately 4 % per year cardiac death rate in the total population. A χ2 = 111.3, p < 0.0001, Pearson's analysis). For the following analysis, NYHA functional class was classified into two groups: NYHA classes I/II and III/IV . Five-year death rates in patients with and without ischemic heart disease were 50 of 245 (20.4 %) and 155 of 688 (22.5 %), respectively (not significantly different). However, causes of cardiac death differed between the ischemic and nonischemic patients. In the former group, only 40 % of deaths were due to progressive heart failure, compared with 72 % in the latter group  died of a cardiac event, including 132 (14.1 %) with heart failure death, 61 (6.5 %) with sudden cardiac death and 12 (1.3 %) with fatal acute myocardial infarction. Five-year cardiac death rates for NYHA classes I to IV were 20 of 221 (9.1 %), 53 of 391 (13.6 %), 100 of 257 (38.9 %) and 32 of 63 (50.8 %), respectively (χ2 = 36.6 and a unit odds ratio (OR) of 0.063; the ROC AUC was 0.717 (p < 0.0001). In patients with NYHA classes III/IV, parameter estimates of HMR showed χ2 = 11.6 and a unit OR of 0.251; the ROC AUC was 0.609 (p = 0.0007).A univariate logistic model using HMR was applied to patient groups with NYHA classes I/II and III/IV, and ROC analysis was performed. In patients with NYHA functional classes I/II, parameter estimates of HMR showed Cox proportional hazard analysis was performed using the variables listed in Table χ2 = 66.7, p < 0.0001), age , LVEF  and male gender . The ROC AUC was 0.749 . In the logistic regression analysis with HMR significant variables were NYHA functional class , HMR , age , male gender  and LVEF . The ROC AUC was 0.780 (95 % CI 0.744 – 0.813). Of the two ROC curves, the model including HMR had a significantly larger AUC (p = 0.0015).In the multivariate logistic regression analysis without HMR significant variables were NYHA functional class . Of the 725 patients who did not die of a cardiac event, 38 were reclassified upward and 103 downward, with a net gain in reclassification of −9.0 % (p < 0.0001). The NRI in all subjects was 13.8 % (p < 0.0001). Thus, model 2 significantly improved the identification of patients at low risk of cardiac death when compared to model 1.The NRI analysis was performed using the four-parameter logistic model created by the combination of NYHA functional class, age, gender and LVEF (model 1) and by the five-parameter model that included late HMR , 0.025 , 0.262 , −0.017  and −1.882  respectively. In this formula, NYHA functional class  and gender  were categorical variables, and age, LVEF and HMR were continuous variables. Representative graphs for 60-year-old patients are shown in Fig. Based on the 5-year logistic regression analysis, mortality rates were estimated using the formula with the five variables model 2)::\documenTo identify the patients at low risk of cardiac mortality (<5 %/5 years), inverse prediction was performed using the logistic model and a single HMR variable in patients with NYHA classes I/II. Based on the plots of mortality risk versus HMR, patients with NYHA classes III/IV were excluded, since 5 % risk per 5 years was not expected to be associated with HMR in the clinical range. The predicted HMR in patients with a 5 % probability of cardiac death in 5 years was 2.02 (95 % CI 1.88 – 2.27). In patients aged ≥65 years and <65 years, the predicted HMR was 2.01 (95 % CI 1.86 – 2.34) and 2.00 (95 % CI 1.79 – 2.67), respectively .Accepted prognostic markers for CHF patients include NYHA functional class, LVEF, BNP levels, and electrocardiographic indices such as QRS duration , 20. Theχ2 value, which might be anticipated given the substantially poorer prognosis in CHF patients with NYHA classes III and IV. Inclusion of HMR reduced the prognostic contribution of LVEF to the model, consistent with the results for all-cause death in the full population, where MIBG showed better discrimination between high-risk and low-risk CHF patients than LVEF [Based on the proportional hazard and logistic regression analyses, five parameters  were selected for the prediction model. Of these parameters, dichotomous NYHA functional class showed the highest OR and han LVEF . This rehan LVEF .Clinically useful diagnostic tools which may aid therapeutic decisions have been developed, and several have examined the additive value of MIBG imaging. The Seattle Heart Failure Model is one of the validated prediction models for estimating mortality risk , 20. ThiIn contrast to the Seattle Heart Failure Model, which included more than 15 variables, a simpler model using a smaller number of readily available clinical variables and MIBG might be more convenient for clinicians involved in the management of CHF patients. An advantage of our five-variable model is that LVEF and MIBG parameters are available from current quantitative software and can be incorporated into a final computer output.Although data from follow-up of nearly 15 years were available in some patients in the original database, the rationale for selecting the 5-year mortality analysis was that this time frame is relevant to the use of most current therapeutic approaches in CHF patients. Risk estimation over 5 years represented a compromise in terms of practical clinical significance, since outcomes during longer follow-up can be affected by many factors, including changes in medication, comorbidities and progression of disease. This type of prediction model has been presented using myocardial perfusion imaging but not previously with MIBG studies, and could facilitate more effective use of the test to understand the risk of future events , 23. TheEstimation of mortality risk in patients with CHF could provide a more rational and cost-effective basis for decisions on specific medications and cardiac devices. In particular, identifying low-risk patients would have immediate practical value. For example, in patients with a prior myocardial infarction who might be at high risk of ventricular tachyarrhythmia, the use of prophylactic therapy with an ICD to improve survival  might beAs noted previously, the present study showed that the HMR as more useful for reclassifying downward into low-risk groups, opposite to the finding in the ADMIRE-HF subanalysis using the Seattle Heart Failure Model. One possible reason for this difference is the difference in patient populations, with the present analyses including patients with NYHA classes I to IV with average LVEF of 36 %, while the ADMIRE-HF study included only those with NYHA classes II and III with average LVEF of 27 %. The mean HMRs in the two studies were 1.71 and 1.44, respectively, suggesting worse functional status in the ADMIRE-HF study. However, this difference could merely reflect technical differences between imaging equipment in Japan versus gamma cameras in the US and Europe. Another potential explanation is the substantially higher prevalence of patients with non-ischemic HF in the Japanese patients (74 %) versus the ADMIRE-HF patients (34 %) and the lower overall mortality in the Japanese HF patients. However, these observations suggest that MIBG imaging might be more effective in reclassifying upward to a higher risk cohort (such as ADMIRE-HF) and downward to a lower risk population such as that examined in this study.Since many patients imaged in the 1990s were included in the present study, BNP was not available for all patients, and it could not be included in the model. However, while single BNP measurements often depend on noncardiac factors such as patient condition and medical treatment, HMR using cardiac MIBG activity is relatively stable and may be more appropriate as a baseline assessment for long-term risk. The present prediction model reflects the derivation cohort, and when applied to other CHF populations, the optimal thresholds of HMR may differ. However, in recent reviews and multicenter studies, the HMR thresholds for low-risk patients have been between 1.6 and 1.8, similar to the findings presented here –9. HMR cThe rates of use of standard CHF medications such as beta blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers and aldosterone inhibitors were lower (30 – 70 %) than in contemporary CHF studies, but these variables were nevertheless not significant in the multivariate analysis. Considering that the earliest patients in the study were examined prior to routine use of many of these medications in CHF patients and that multiple medication changes might have occurred during long-term follow-up, the relevance of this observation is uncertain. Information on other cardiac medications, such as diuretics and those used to treat arrhythmias, such as amiodarone, was also not included in the database. Of note, the associated conditions of diabetes, dyslipidemia and hypertension were not predictors of cardiac death in the study population.The present study confirmed the long-term prognostic value of MIBG imaging in CHF patients and supported development of a potentially useful five-variable prediction model for cardiac death. The prediction model can be used as the basis for graphical nomograms or computer applications to assist clinicians in stratifying risk in their CHF patients. With further validation, these methods could contribute to improvements in the quality and cost-effectiveness of CHF patient care.ESM 1A supplemental figure of all age groups attached for on-line (adjunct to Figure Below is the link to the electronic supplementary material.


Pulse pressure (PP) is a risk factor for cardiovascular disease. It has been reported that ambulatory blood pressure (BP) and nighttime BP parameters are heritable traits. However, the genetic association of pulse pressure and its clinical impact remain undetermined.We conducted a genome-wide association study of PP using ambulatory BP monitoring in young-onset hypertensive patients and found a significant association between nighttime PP and SNP rs897876 (p = 0.009) at chromosome 2p14, which contains the predicted gene FLJ16124. Young-onset hypertension patients carrying TT genotypes at rs897876 had higher nighttime PP than those with CT and CC genotypes . The T risk allele resulted in a cumulative increase in nighttime PP . An independent community-based cohort containing 3325 Taiwanese individuals  was studied to investigate the genetic impact of rs897876 polymorphisms in determining future cardiovascular events. After an average 7.79±0.28 years of follow-up, the TT genotype of rs897876 was independently associated with an increased risk (in a recessive model) of coronary artery disease  and total cardiovascular events , suggesting that the TT genotype of rs897876C, which is associated with nighttime pulse pressure in young-onset hypertension patients, could be a genetic prognostic factor of cardiovascular events in the general cohort.The TT genotype of rs897876C at 2p14 identified in young-onset hypertensive had higher nighttime PP and could be a genetic prognostic factor of cardiovascular events in the general cohort in Taiwan. Hypertension is a leading cause of death, especially in highly industrialized regions, and is considered to be the major risk factor for cardiovascular disease Pulse pressure (PP), the difference between systolic blood pressure and diastolic blood pressure, represents the hemodynamic load on the vasculature and indirectly measures central aortic stiffness. It has been reported that higher PP is associated with left ventricle hypertrophy Ambulatory blood pressure (ABP) monitoring is a validated and accurate method to evaluate blood pressure during a 24-hour period. The correlation between blood pressure (BP) level and target organ damage, cardiovascular disease (CVD) risk, and long-term prognosis is greater via ABP monitoring than official BP measurements. Additionally, PP heritability is higher (0.47–0.57) when using ABP measurements rather than single-point measurements. This indicates that higher heritability is associated with an increased number of BP measurements; therefore, ABP monitoring is more appropriate for the study of the genetics of essential hypertension A two-step genetic association analysis of young-onset hypertension was performed to analyze the genetic association of ambulatory PP in young-onset hypertension. In the first step, a GWAS was conducted with young-onset hypertensive patients as the discovery group (n = 382) to find significant SNP markers. In the second step, a replication study was conducted to test whether SNP markers filtered in first stage were significantly associated with PP in the replication samples (n = 559). The diagnostic criteria for young-onset hypertension have been published previously To determine the clinical implications of a genetic association with pulse pressure found in young-onset hypertension, CardioVascular Disease risk FACtors Two-township Study (CVDFACTS), a cohort study (n = 3325), was selected for investigating the association of future cardiovascular events and the genetic risk variants. The CVDFACTS cohort is a community-based follow-up study begun in 1989 to investigate the cardiovascular disease occurrence and risk factors in Taiwan We calculated the power of our two-stage genetic association study using CaTS software −7), call rates <95%, or minor allele frequency <1%. Genotyping for the verification study and subsequent genotyping of subjects in the CVDFACTS study were conducted using the Sequenom MassARRAY System  by the Academia Sinica National Genotyping Center .Genomic DNA was extracted from peripheral blood samples of hypertensive subjects using the Puregene DNA isolation kit  for the young-onset hypertension genetic study and using the phenol/chloroform method for CVDFACTS. For the GAWS, genotyping experiments were performed with leukocyte DNA using the Illumina Infinium II HumanHap550 SNP chips , which included 560,186 tagging SNPs selected from phase I and II of the HapMap Project. Genotyping assays were performed by deCODE genetics  for 382 young-onset hypertensive subjects in the first stage of the study. We followed the WTCCC criteria for quality control; in brief, individuals were excluded if more than 3% of the genotype data were missing. SNPs were excluded if they showed violation of the Hardy-Weinberg equilibrium  were analyzed separately. To estimate the effect of genetics in determining ambulatory BP, a stepwise linear multiple regression model was used. The genome-wide significance threshold for the p-value was 5×10−7) for the trait of nighttime PP was rs6696698, located on chromosome 1  in the replication study . mosome 1 . Multidimosome 1 . In the To determine the clinical significance of the nighttime PP-associated SNP found among young-onset hypertensive, genotyping for rs897876 was performed in a prospective cohort study, the CVDFACTS study, to evaluate the association of future cardiovascular events with rs897876. The genotype call rate was above 99.4%. The CVDFACTS study enrolled a total of 3325 subjects, 1513 males and 1812 females, with a mean age of 50.2±12.3. The CVDFACTS cohort used in this study consisted of a total of 389 hypertensive patients, 204 (52%) of whom were young-onset hypertensive patients. The young onset hypertensive subjects have higher diastolic blood pressure and higher BMI. Subject with hypertension diagnosed after age 50 have higher fasting glucose, and higher triglyceride values . After aIn our present study, we first identified rs897876 at 2p14, which is highly associated with nighttime pulse pressure in young-onset hypertension. Subjects who carried the TT genotype at rs897876 had higher nighttime PP, indicating that the T allele of rs898786 is an independent predictor associated with higher nighttime PP . Furthermore, the T allele of rs897876 was associated with an increased risk of developing future CAD and total cardiovascular events in an independent cohort. Consequently, the T allele of rs897876 could be a genetic prognostic factor for long-term outcomes in general cohort that include hypertensive patients and could be seen as a genetic marker for advanced cardiovascular events. Furthermore, 2p14 is a locus of interest for further investigation.Recent large-scale GWAS have reported more than 20 novel loci for SBP and DBP where alleles have effect sizes of up to 0.5–1 mm Hg SPRED2 (65M) is a negative regulator of the hypothalamic-pituitary-adrenal axis and contributes to the modulation of hyperaldosteronism and homeostatic imbalances RAB1A (65M) has been reported to be associated with cardiomyopathy 2 = 0.83) as well as pulse pressure (PP) . Further studies will be required to clarify functional relation between FLJ12164 and TGFA responsible for blood pressure regulation. Interestingly, a recent linkage study investigating heritability of PP among Chinese twin pairs found3 linkage peaks on chromosomes 11, 12 and 18 It is interesting that different gene sets seem to contribute to the regulations of daytime and nighttime ambulatory BP. This finding is in accordance with previous findings that the gene sets that regulate daytime and nighttime blood pressure overlap, but there is a genetic component that is specific to the nighttime BP control In our study, the T allele of rs897876 located on 2p14 was independently associated with an increased risk of CVD in a prospective cohort. Currently, accumulating evidence demonstrates that ambulatory BP is a better predictor of morbidity and mortality than conventional BP There are some limitations to our study. There were not many significant associations between individual risk alleles and clinical events in the cohort. This result was expected given that alleles of small effect were tested in a community-based sample of modest size. Although none of the SNP markers achieved genome-wide significance in our first stage GWAS due to small sample size, the second stage replication study still revealed significant loci related to nighttime PP. Further studies with larger sample size and different ancestry groups followed by additional functional confirmation studies are warranted. The second limitation of this study is that ambulatory BP monitoring was not available in the CVDFACTS cohort. The finding that the T allele of rs897876 is associated with nighttime PP was found using ABP monitoring, but the association between 24-hour ambulatory BP parameters among subjects in CVDFACTs could not be evaluated.In conclusion, we first identified rs897876 at 2p14 to be highly associated with nighttime PP in young-onset hypertension patients. Subjects carrying the TT genotype of rs897876 had a higher nighttime PP, suggesting that the T allele of rs897876 was an independent predictor in determining ambulatory nighttime PP. Although the function of this locus is not well understood, the CVDFACTS prospective cohort study clearly demonstrated that the TT genotype at rs897876 on 2p14 is significantly associated with an increased risk of future cardiovascular events. This suggests that rs897876 could be a genetic prognostic factor for cardiovascular events in a general cohort in Taiwan and that 2p14 may have an important role in the pathogenesis of cardiovascular diseases.Figure S1Multidimensional scaling (MDS) analysis plot. The MDS plot shows the first two principal components, estimated by PLINK, based on genotype data from 509,174 SNPs. No population stratification for YOH cases in the first stage was detected .(TIF)Click here for additional data file.Table S1Top ten Eigen vectors of the covariance matrix between the initial stage and the second stage.(DOCX)Click here for additional data file.Table S2Baseline characteristics of patients with essential hypertension.(DOCX)Click here for additional data file.


Pulse wave velocity was increased  and carotid distensibility was decreased  in this group compared with the group born at term. However, the global and peripheral arterial stiffness measured by CAVI and brachial ultrasound did not differ . Adults who are born preterm have significant differences in their aortic structure from adults born at term, but they have relatively small differences in central arterial stiffness that may be partially explained by blood pressure variations.Preterm birth is associated with higher blood pressure, which could be because preterm birth alters early aortic elastin and collagen development to cause increased arterial stiffness. We measured central and conduit artery size and multiple indices of arterial stiffness to define the extent and severity of macrovascular changes in individuals born preterm. A total of 102 young adults born preterm and 102 controls who were born after an uncomplicated pregnancy underwent cardiovascular magnetic resonance on a Siemens 1.5 T scanner to measure the aortic cross-sectional area in multiple locations. Ultrasound imaging with a Philips CX50 and linear array probe was used to measure carotid and brachial artery diameters. Carotid-femoral pulse wave velocity and the augmentation index were measured by SphygmoCor, brachial-femoral pulse wave velocity by Vicorder and aortic pulse wave velocity by cardiovascular magnetic resonance. The cardio-ankle vascular index (CAVI) was used as a measurement of global stiffness, and ultrasound was used to assess peripheral vessel distensibility. Adults born preterm had 20% smaller thoracic and abdominal aortic lumens (2.19±0.44  For example, in experimental models, the elastin and collagen maturation that occurs in the arterial wall during late gestation is prematurely halted by an early transition to postnatal physiology.8 Perinatal interventions used in preterm neonates, such as antenatal glucocorticoids and intravenous lipids, are also known to modify connective tissue architecture and function in the aortic arch and abdominal aorta, respectively.10 Therefore, permanent changes in arterial size and stiffness may underlie the observed increase in hypertension risk in the offspring of women with complicated pregnancies,11 particularly in individuals who are born preterm.13Advances in neonatal care have led to a rise in perinatal survival of those born preterm.16 and increased arterial stiffness18 in preterm offspring. However, others have failed to replicate these findings.21 This variability may have occurred because several studies had small sample sizes or because elastin content and exposure to perinatal hemodynamic stress varied between arterial locations, resulting in localized changes in arterial stiffness. Additionally, pulse wave velocity is known to change with blood pressure at the time of measurement, and stiffness has not been assessed with more recent indices known to be independent of blood pressure. Therefore, we compared central and conduit artery size in a large group of adults born preterm to measurements in term-born adults. Then, we characterized their global arterial stiffness using pulse wave velocity and the cardio-ankle vascular index (CAVI) to take into account the physiological impact of the known variation in blood pressure.Apparently consistent with this hypothesis, several studies have reported reduced vessel size10 At follow-up during adolescence, 240 of the initial 926 participants (birthweight <1850 g) agreed to be contacted about future studies. We performed detailed cardiovascular phenotyping on 102 of the participants at age 23–28 years.10 For this study, 102 adults who had been born at term to women with uncomplicated pregnancies, with frequencies matched to the age and sex distributions of the preterm adults, were recruited to undergo identical investigations. The study was registered with ClinicalTrials.gov (NCT01487824), and the protocols were approved by the relevant ethics committee (Oxfordshire Research Ethics Committee A: 06/Q1604/118). All participants provided signed informed consent.A cohort of individuals born preterm between 1982 and 1985 has been prospectively followed since recruitment at birth to a randomized feeding intervention trial.22 Briefly, preterm perinatal data were collected from medical records during the first weeks of life, with participant maternal recall used to validate birth history in term-born adults.10 Blood pressure was measured after 10 min of supine rest based on an average of the last two out of three left brachial blood pressure recordings using an automatic digital monitor .10 Anthropometry measurements included height, weight and skinfold thickness. Medical and lifestyle information was collected using a questionnaire.24 Blood samples were collected following a 12 h overnight fast and were centrifuged and separated within 30 min for storage at −80 °C before analysis. Fasting lipid profiles and metabolic measurements were conducted at the John Radcliffe Hospital  Biochemistry Laboratory using validated clinical assays.Details of sample and data collection have been previously reported.10 Minimum aortic cross-sectional areas at the end-diastole were determined by using semi-automated edge detection algorithms .25Cardiovascular magnetic resonance was performed on a 1.5 T  scanner. The aortic cross-sectional area was measured from axial ECG-gated, steady-state free precession cine images acquired during breath holding at the level of the pulmonary artery  and at the level of the second lumbar vertebra .Conduit vessel size was measured using a Philips CX50 ultrasound machine with a 12 MHz linear array transducer. The participant lay supine in a temperature-controlled room. Following 10 min of rest, ECG-gated longitudinal images of the right brachial artery were acquired 5–10 cm above the antecubital fossa. The carotid arteries were imaged with the patient lying flat and the head rotated to the opposite side from the carotid measure. The carotid bifurcation was identified, and then a longitudinal image was acquired that included the bulb and common carotid artery so that diameter could be measured 1 cm proximal to the bifurcation. The minimum arterial diameter at the end-diastole was measured offline using automated image analysis software .26 Aortic pulse wave velocity was calculated as the distance between the assessed sites  measured on an aortic oblique sagittal image divided by the time delay between the arrival of the foot of the pulse wave at each site, which was determined as the intersection of the tangent of the upslope of the flow curve with the x-(time)axis.28The aortic pulse wave velocity was measured using free breathing and retrospectively ECG-gated with a spoiled gradient echo sequence. The velocity-encoding gradient for phase contrast was applied to measure the through-plane flow in the same position as the aortic size measurements at the level of the pulmonary artery and distal descending aorta. Image analysis was performed with Argus . Flow images were manually contoured as previously described.29The carotid-femoral pulse wave velocity was measured using applanation tonometry to obtain pressure waveforms of the carotid and femoral pulse . Brachial-femoral pulse wave velocity was measured using sphygmomanometer-derived indices  with cuffs placed around the brachial and femoral arteries to identify the pulse arrival. With both techniques, the pulse wave velocity is derived from recordings of the time delay between the two measurement sites relative to the distance between them identified from predefined landmarks. The augmentation index was automatically measured from the pressure waveforms of the radial pulse obtained by applanation tonometry adjusted to a mean heart rate of 75 beats per minute . Minimum and maximum arterial diameters of the carotid and brachial arteries were measured offline from stored ultrasound image loops acquired over multiple cardiac cycles. Carotid and brachial diameters were measured using automated image analysis software . The distensibility of these arteries was quantified as the change in diameter relative to the minimum diameter proportional to the pulse pressure based on central and peripheral measurements recorded during the ultrasound image acquisition.31In a subgroup of participants, CAVI was measured with the VaSera VS-1500 . CAVI is an indicator of the stiffness of arteries from the origin of the aorta to the ankle of the lower leg. The measurement is developed from the stiffness parameter β and is independent of blood pressure at the time of measurement.t-test; the Mann–Whitney test was used for skewed data. The results are presented as the mean±s.d. P-values <0.05 were considered statistically significant. Comparisons between groups of categorical variables were performed using a X2-test. Linear regression was performed using backwards stepwise models.Statistical analysis was performed using SPSS Version 20 . Normality was assessed using visual assessment of histograms and the Shapiro–Wilk test. Comparisons between groups for continuous variables for normally distributed data were performed using a two-sided, independent-sample Student's 7 Briefly, at the time of the study visit, there were no significant differences between preterm and term-born individuals in the number of smokers, personal and family medical histories or lifestyle factors such as physical activity, diet or socioeconomic status. However, the adults born preterm were shorter, weighed more and had higher blood pressure than the young adults in the cohort born at term. Participants with CAVI-derived arterial measurements had characteristics similar to the full cohort . Similar differences were observed between the centrally measured systolic and diastolic blood pressures . The amplification from central to brachial systolic blood pressure was 2 mm Hg lower in the preterm group than in the those born at term, but this difference did not reach statistical significance . There was no evidence for significant amplification of diastolic blood pressure As previously reported for this cohort,2vs. 23.87±3.55 mm2, respectively, P=0.64, 2vs. 8.57±2.91 mm2, respectively, vs. 2.69±0.60 cm2, P<0.001 and 1.25±0.36 vs. 1.94±0.45 cm2, P<0.001, respectively). These results were not substantially changed in a multivariate model that included measurements of body size and mean blood pressure.There was no evidence of a reduced carotid artery lumen cross-sectional area in the participants born preterm , but not brachial distensibility , and had a significantly higher augmentation index . However, in a multivariate analysis of measurements of arterial stiffness, the magnitude and significance of the differences in pulse wave velocity and distensibility were markedly attenuated after the inclusion of mean blood pressure (n=27 preterm and n=94 term), there were no significant differences in arterial stiffness between the groups . There was a significant correlation between the central mean arterial pressure and abdominal aortic size as well as a trend for an association between amplification from the central to brachial systolic blood pressure and abdominal aortic area  but not the thoracic aortic area  in those born preterm. However, the coefficient suggests only ~4% of the variation in blood pressure is related to aortic size, with a trend for an even smaller degree related to variations in thoracic aortic diameter . There was no consistent relationship between measurements of pulse wave velocity or peripheral distensibility and aortic luminal area. Therefore, any association is likely to be driven by factors common to both aortic size and changes in wave reflection independent of arterial stiffness per se. There is a relationship between gestational age and thoracic  aortic size in the preterm cohort  that is consistent with an impact of preterm birth on aortic development but not with aortic stiffness  r<0.01, P=0.98).There was a moderate inverse relationship between the augmentation index and both the thoracic and abdominal aortic luminal area . In a previous study, we reported a similar degree of variation in pulse wave velocity based on a single tonometry-derived index in adults born preterm whose mothers were normotensive.22 In the current study, we used three different pulse wave velocity technologies, each with unique approaches for the assessment of arterial stiffness . All three showed similar degrees of change. We previously reported that perinatal management, such as the use of antenatal steroids and intravenous lipid feeding regimens, could have an impact on different regions of the aorta.10 Taken together, these findings suggest arterial stiffness does differ in early adulthood in association with a preterm perinatal history.22 However, data from the ENIGMA study of young healthy adults demonstrated that carotid-femoral pulse wave velocity increased by 0.5 m s−1 for each 10 mm Hg increase in mean arterial pressure,35 and reference values published by the Arterial Stiffness Collaboration in 201036 described a beta coefficient of mean arterial pressure with a pulse velocity of 0.047 m s−1 for a 1 mm Hg rise in a population with a similar age to our study population. Therefore, the majority of the differences in pulse wave velocity (PWV) demonstrated in this study could be accounted for by the variation in blood pressure between groups rather than true pathological differences in arterial stiffness; this possibility was confirmed in our multivariate analysis. This result would be consistent with the findings of the EPICURE follow-up study of school age preterm children17 in which there was a relatively small difference in blood pressure and no evident difference in aortic stiffness.Despite significant localized changes in aortic size, there appears to be only small differences in aortic stiffness. Although pulse wave velocity differed significantly between the groups, the degree of change was relatively small  and blood pressure5 on vascular measurements. A potential weakness of the study was that several technologies became available during the course of our follow-up. Therefore, some of the arterial stiffness measures (such as CAVI) were available in only a subgroup. However, the findings from these measurements are in accord with those performed in the full cohort. Because we do not have measurements of vessel size in childhood, it is possible that all vessels were originally smaller but that the conduit vessels have undergone a compensatory adaptation in adulthood. Longitudinal studies of the vasculature may be of value to study this hypothesis.To the best of our knowledge, this is the largest cardiovascular magnetic resonance study of preterm offspring. Cardiovascular magnetic resonance is an accurate and safe modality for measuring aortic dimensions, although it should be noted that it is not as precise as some other non-invasive techniques in terms of temporal resolution for the assessment of arterial stiffness.In conclusion, there is a localized reduction in aortic size in adults born preterm, although the carotid and brachial arteries are not smaller. Nevertheless, this finding does not result in clinically relevant changes in global arterial stiffness, as assessed by pulse wave velocity, and it seems unlikely that changes in arterial stiffness account for increased cardiovascular and cerebrovascular risk in adults born preterm. However, these risks may increase later in life. Those born preterm have elevated blood pressure from a young age and therefore may be particularly prone to accelerated vascular ageing.


Several proangiogenic molecules have been implicated in the pathogenies of asthmatic inflammation and remodeling. The aim of the study was to compare the concentration of proangiogenic factors in the sera of asthmatic patients and in healthy subjects (HS), and to refer the concentrations to both clinical and inflammatory markers of the disease severity.Serum was collected from 45 patients with severe/refractory asthma (SRA) and 51 patients with non-severe asthma (nSA). The control group included 30 HS. Serum concentrations of Angiopoietin-1, Angiopoietin-2, vascular endothelial growth factor (VEGF) and osteopontin were assessed by the enzyme-linked immunosorbent assay.The levels of Angiopoietin-1 , Angiopoietin-2  and VEGF were significantly higher in asthmatic patients (n = 94) as compared to HS . The mean serum level of Angiopoietin-2 was found to be significantly higher in patients with SRA as compared to nSA patients . Angiopoietin-2 serum level correlated with respiratory function and with parameters of asthma severity: the mean number of asthma exacerbations in the preceding 12 months , mean number of emergency visits due to severe asthma exacerbation  and mean number of hospitalizations  or dose of inhaled glucocorticosteroids taken by the patients .Angiopoietin-2 seems to be a crucial proangiogenic cytokine overproduced in patients with SRA characterized by repeated exacerbations and Angiopoietin-2 serum levels can serve as a biomarker of severe asthma. Asthma has been defined as ‘‘a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and an underlying inflammation” . BronchiAngiogenesis is a process of wound healing and organ development taking place throughout life, and the mechanisms responsible for the formation of new vessels have been extensively studied –10. The The aim of the study was to compare serum levels of proangiogenic factors: Angiopoietin-1, Angiopoietin-2, VEGF and osteopontin in asthmatic patients and in healthy subjects (HS), and to refer their concentrations to the severity of asthma, clinical asthma phenotypes and inflammatory markers in serum.Sera were collected from 96 well characterized patients with bronchial asthma  recruited from the Asthma Clinic, Department of Immunology, Rheumatology and Allergy, Medical University of Lodz. Based on American Thoracic Society (ATS) Workshop 2000 definitions asthmatics with severe/refractory asthma (SRA) were distinguished . PatientThe study was approved by local Ethical committee and all patients signed informed consent to the study.D. pteronyssinus, D. farinae, cat, dog, trees, grass mix, weeds, Alternaria tenuis. Aspirin hypersensitivity was diagnosed based on convincing history of adverse reaction to non-steroidal anti-inflammatory drugs (NSAIDs) and confirmed by a bronchial challenge with lysine aspirin [2).Atopy was determined based on the positive result of at least one skin prick test. In all patients skin prick tests were performed  and a wheal diameter of 3 mm or more in excess of the negative control was considered a positive result. The following allergens were tested:  aspirin . Body ma1, FEV1/FVC, MEF 25-75) was measured with an automatic spirometer  when patients were without inhaled short acting b2 agonists for at least 8 h and long acting b2 agonists for at least 12 h. Airway reversibility was assessed 15 min after nebulization of 2.5 mg of albuterol . The results were expressed as the best measurement and maximal % change from baseline.Respiratory function .Concentrations of Angiopoietin-1 (sensitivity 10.3 pg/ml), Angiopoietin-2 (sensitivity 21.3 pg/ml), VEGF (sensitivity 9 pg/ml) and osteopontin (sensitivity 0.024 ng/ml) were assessed by enzyme-linked immunosorbent assay . Total IgE, Eosinophil cationic protein (ECP) were measured in serum with ImmunoCAP system (Data are presented as mean ± SEMs (standard errors) or ±SD (standard deviation) as indicated. The data distribution was tested by Kolmogorov–Smirnov test. The following statistical methods were applied as appropriate and as indicated in the text: Spearman test to assess correlation, exact Fisher test, analysis of variance Kruskal–Wallis followed by post hoc Dunn’s multiple comparison test. Models of logistic regression were applied to assess the risk of SRA. p values <0.05 were considered to be significant.Based on the ATS criteria 45 patients were diagnosed to have SRA and the remaining 51 patients were assigned to the non-severe (nSA) asthma group (mild and moderate severity based on the GINA criteria) , Angiopoietin-1  and VEGF  were significantly higher in asthmatic patients as compared to HS. However, the mean osteopontin levels were significantly lower as compared to controls .When asthmatics were stratified according to the severity, the mean serum level of Angiopoietin-2 was found to be significantly higher in patients with SRA as compared to nSA , and in both asthma groups mean Angiopoietin-2 levels were higher as compared to HC   FEV1/FVC value  and MEF 25-75  was found. Angiopoietin-2 correlated also with airway obstruction reversibility defined as percentage of increase in FEV1 after inhalation of 2.5 mg of salbutamol . Angiopoietin-2 correlated also with BMI of patients  and duration of the asthma .For the whole asthma group inverse correlation of serum Angiopoietin-2 levels with respiratory function parameters: FEVIn the whole asthma group (n = 96) we did not find any association of Angiopoietin-2 or other angiogenic factors with patients’ atopic status, presence of aspirin hypersensitivity, BMI or smoking status. However, within SRA group in patients with aspirin hypersensitivity (n = 12) the mean VEGF serum levels were significantly higher as compared to aspirin tolerant individuals .Serum concentrations of Angiopoietin-2, VEGF, Angiopoietin-1 and osteopontin did not correlate with classical markers of asthma severity or asthmatic inflammation: blood eosinophil number and serum ECP or total IgE levels. Significant correlations were found between Angiopoetin-2 and osteopontin , Angiopoietin-1 and osteopontin  or Angiopoietin-1 and VEGF  levels.In this study involving relatively large and heterogeneous group of patients with asthma we documented that serum levels of Angiopoietin-2, were not only significantly increased in the asthmatics as compared to the healthy control subjects randomly selected from the general population, but also were associated with severe refractory asthma phenotype. Patients with asthma, regardless of the diseases severity had on average almost threefold higher mean Angiopoietin-2 serum levels and significantly increased Angiopoietin-1 and VEGF serum concentrations, reflecting probably ongoing angiogenesis in the airways.We were able to distinguish a subpopulation of the asthma patients who despite high doses of oral and inhaled glucocorticosteroids suffered from severe asthma with low pulmonary function and frequent exacerbations. These patients, who fulfilled the ATS criteria for SRA, had significantly increased Angiopoietin-2 levels as compared to the patients with mild/moderate asthma. Moreover, Angiopoietin-2 serum levels correlated with several clinical features of asthma severity and control including chronic dose of inhaled glucocorticosteroids, number of asthma exacerbations, emergency room interventions and even number of hospitalizations during the preceding year. Our results are in line with an earlier report of increased levels of both Angiopoietin-1 and 2 , 22 in t1, MEF 25-75 of predicted value, which suggests that local generation of this proangiogenic factor may have an effect on asthmatic airways function. A positive correlation found between Angiopoietin-1 levels and airway obstruction reversibility, may reflect involvement of this factor in the modulation of a smooth muscle constriction.We were able to demonstrate modest, but significant inverse correlation between the Angiopoietin-2 serum levels and FEVIn an earlier study Angiopoietin-2 rather than Angiopoietin-1 was associated with asthma and Angiopoietin-1/Angiopoietin-2 ratio was positively correlated with lung function in adult asthma patients . More reWe found positive association of Angiopoietin-2 levels with asthma exacerbation defined as unscheduled visits in the clinic, emergency interventions or hospitalization. Although etiology of asthma exacerbation is multifactorial, the most common triggers are related to the respiratory infections. It has been previously demonstrated that rhinovirus infection can stimulate release of VEGF, although it had no impact on angiopoietin levels , 25. IntAngiopoietins (both Angiopoietin-1 and 2), which are involved in a new vessels formation in various organs are small molecules released from various cells. In addition, acting through specific Tie-2 receptor which is expressed not only on endothelial cells, but also on eosinophils and neutrophils , 28 angiIn our study proangiogenic factors other than Angiopoietin-2, did not correlate so well with asthma phenotypes. Serum levels of VEGF were higher in asthmatics as compared to HS, but no correlation with the disease severity was found. Interestingly in our study VEGF was significantly increased in patients with severe asthma and coexisting aspirin hypersensitivity. Patients with aspirin exacerbated respiratory diseases (AERD) usually have more severe asthma and were shown to have more pronounced airway remodeling . It has Our study have confirmed and extended previous observations suggesting an imbalance between various proangiogenic factors in patients with bronchial asthma. Increased serum levels of proangiogenic Angiopoietin-2 in asthmatics and its association with clinical markers of asthma severity, including exacerbations, may reflect ongoing airway inflammation. Further studies are required to assess if Angiopoietin-2 serum level can serve as a biomarker of asthma severity and remodeling.


Whether distal inflammation in asthmatics also leads to structural changes in the alveolar parenchyma remains poorly examined, especially in patients with uncontrolled asthma. We hypothesized that patients who do not respond to conventional inhaled corticosteroid therapy have a distinct tissue composition, not only in central, but also in distal lung.Bronchial and transbronchial biopsies from healthy controls, patients with controlled atopic and patients with uncontrolled atopic asthma were processed for immunohistochemical analysis of fibroblasts and extracellular matrix molecules: collagen, versican, biglycan, decorin, fibronectin, EDA-fibronectin, matrix metalloproteinase (MMP)-9 and tissue-inhibitor of matrix metalloproteinase (TIMP)-3.In central airways we found increased percentage areas of versican and decorin in patients with uncontrolled asthma compared to both healthy controls and patients with controlled asthma. Percentage area of biglycan was significantly higher in both central airways and alveolar parenchyma of patients with uncontrolled compared to controlled asthma. Ratios of MMP-9/TIMP-3 were decreased in both uncontrolled and controlled asthma compared to healthy controls. In the alveolar parenchyma, patients with uncontrolled asthma had increased percentage areas of collagen, versican and decorin compared to patients with controlled asthma. Patients with uncontrolled asthma had significantly higher numbers of myofibroblasts in both central airways and alveolar parenchyma compared to patients with controlled asthma.Tissue composition differs, in both central and distal airways, between patients with uncontrolled and controlled asthma on equivalent doses of ICS. This altered structure and possible change in tissue elasticity may lead to abnormal mechanical properties, which could be a factor in the persistent symptoms for patients with uncontrolled asthma. Asthma is a chronic inflammatory airway disease that is traditionally characterized by reversible central airway obstruction and airway hyperreactivity ,2. Altho1, the alternatively spliced domain A of fibronectin (EDA-fibronectin) as well as mechanical force [1, acting as structural components in tissue organization by forming large complexes with hyaluronan and collagens, as well as cell signaling affecting differentiation, migration and inflammation [In an inflammatory environment such as the asthmatic airway, fibroblasts are activated to myofibroblasts, which deposit molecules including collagens and proteoglycans into the surrounding extracellular matrix -13. Myofal force . Proteogammation -17. The ammation . A disruammation .We have previously shown that increased collagen deposition occurs in alveolar parenchyma already in patients with mild untreated asthma . HoweverThe present study included 9 patients with controlled atopic asthma and 16 patients with uncontrolled atopic asthma according to GINA guidelines and asthma control test (ACT) ,21. UncoFrom each patient, central airway biopsy specimens (n = 5) were taken from the segmental or subsegmental carina in the right lower and upper lobes, followed by sampling of transbronchial biopsy specimens (n = 5) in the right lower lobe. In total, 330 biopsies were collected. Bronchoscopy was performed as previously described . BronchoFor processing of tissue, see Additional file All antibodies used have been extensively validated for staining of human tissue in research and routine clinical diagnosis  was used for simultaneous visualization of versican and decorin. A single staining protocol  was used for visualization of biglycan, fibronectin, EDA-fibronectin, MMP-9 and TIMP-3. The immunohistochemistry protocols were performed using an automated immunohistochemistry robot . Sections were stained with Mayer’s haematoxylin for visualisation of background tissue and mounted. For details see Additional file Stained slides were digitally scanned using ScanScope . All markers were quantified in blinded sections in central airways  and alveolar parenchyma . The immunoreactivity (% positively stained area) of versican, decorin, biglycan, fibronectin, EDA-fibronectin, MMP-9 and TIMP-3 as well as the tissue area in the walls of bronchi and in the alveolar septa was calculated using Visiomorph™ . The percentage stained area was calculated dividing the stained area by the total selected area. The image analysis program calculated the tissue area of the whole biopsy, excluding air spaces so that only tissue  was measured. Glands were excluded from the analysis by manual detection.2) using Visiomorph™ (Visiopharm). For details see Additional file The density of fibroblasts and myofibroblasts was counted manually and calculated either as double positive for prolyl 4-hydroxylase (P4OH) and vimentin (fibroblasts) or triple positive for αSMA, P4OH and vimentin (myofibroblasts). The number of cells was related to tissue area  fluid and sputum samples was measured by enzyme-linked immunosorbent assay (ELISA) .Data are presented as median values together with interquartile range unless otherwise stated. Non-parametric Mann–Whitney was used for comparison between two groups with Bonferroni post hoc test for correction of multiple comparisons. Correlation analysis was performed using Spearman rank correlation test. Critical p values  were adjusted according to Bonferroni. Subsequently, alpha values of <0.017 (*), <0.0033 (**) and <0.00033 (***) denote significant levels of difference. All analysis was performed using GraphPad Prism version 6.0a software .An overview of patient characteristics is presented in Table 1 % predicted was lower in patients with uncontrolled asthma compared to healthy controls (p = 0.018). FeNO was higher in patients with uncontrolled asthma compared to controls (p = 0.001). There was no significant difference in alveolar NO between patients with uncontrolled asthma and controls.Two patients were treated with leukotriene-receptor antagonist; three patients were treated with antihistamines and two with nasal steroids. FEV1 % predicted or exhaled NO between healthy controls and patients with controlled asthma. All asthmatics were treated with inhaled glucocorticosteroids and inhaled bronchodilators. All asthmatics were non-smokers although three were ex-smokers.There was no difference in FEVMasson’s trichrome staining was used to examine total collagen content Figure . In the In central airways, versican and decorin expression was seen in elastic fibers in the lamina propria Figure E-G. DecoExpression of MMP-9 was primarily seen in columnar cells in the airway epithelium and in inflammatory cells in the lamina propria and adventitia of the central airway wall and in cells located in the alveolar septa, Figure In central airways, there was an increased percentage area of TIMP-3 in patients with uncontrolled asthma compared to healthy controls (p = 0.087), Figure s = −0.75, p = 0.008).Triple positive myofibroblasts  were found in central airway wall, predominantly situated just below the reticular basement membrane. In central airways, patients with controlled asthma had significantly fewer myofibroblasts than patients with uncontrolled asthma (p < 0.0001), Figure Expression of fibronectin and EDA-fibronectin was measured in central airways and alveolar parenchyma in patients with controlled and uncontrolled asthma and healthy controls. No difference in total fibronectin percentage area was found between healthy controls and asthmatics in either central airways or alveolar parenchyma, Additional file This study shows that the bronchial wall and alveolar parenchyma have an altered composition of matrix that differs between patients with controlled and uncontrolled asthma on equivalent doses of ICS, which could contribute to the symptoms in patients with uncontrolled asthma.1 plays a central role in airway remodeling and has been found to induce production of several types of collagens from myofibroblasts [Due to the inaccessibility of tissue from alveolar parenchyma of asthmatic patients little is known regarding the remodeling processes in the peripheral lung and how these changes contribute to asthma pathology . The preroblasts ,23. Althroblasts  there waroblasts , which r1in vitro[et al. showed that, in vivo, only decorin and not biglycan was found to interfere with TGF-β1 activity [1 signaling [in vitro studies of collagenases has shown [Biglycan and decorin are two small leucine-rich proteoglycans involved in collagen fibrillogenesis and fibril stabilization in the tissue . Both de1in vitro. Howeveractivity . In addiignaling . In thisas shown , which cas shown -32. CharVersican is a large proteoglycan that is highly interactive with several matrix components including hyaluronan and fibrillin ,34. IncrThere was a decreased ratio between MMP-9 and TIMP-3, in central and distal airways of both patient groups, which indicates a proteolytic-antiproteolytic imbalance. Although, since the ratio is decreased in both patient groups it does not explain the differences in percentage areas of matrix molecules between patients with controlled and uncontrolled asthma. Additional analyses of other MMPs, TIMPs and their relationship with structural alterations in the lung tissue need to be further examined. Taken together, these structural alterations affect phenotypes of cells and the biomechanical properties of the lung.1 mRNA as well as immunoreactivity have been found to be increased in the airways submucosa of asthmatic patients, with a direct correlation to the severity of the disorder [1[The fibroblasts/myofibroblasts play a pivotal role in remodeling processes as the main extracellular matrix producing cells. Corticosteroids have been found to prevent myofibroblast accumulation and airway remodeling in mice . Interesdisorder . Interlesorder [1-44.1 in modulating fibroblasts into the activated myofibroblast phenotype [EDA-fibronectin cooperates with TGF-βhenotype . The incin vitro and in vivo animal and human studies often show conflicting results. This matter is further complicated by the possibility that myofibroblasts respond differently to steroids in some patient-groups which is concordant with the heterogeneity of asthma.The differences in myofibroblast numbers, in patients with controlled asthma compared to uncontrolled asthma, raises the question how the ICS treatment affects the tissue and why it varies between patient groups. Could it be due to differences in steroid-sensitivity, or does the inhalation therapy not reach the peripheral airways? Indeed, in patients with controlled asthma there was a negative correlation between numbers of myofibroblasts and daily dose of ICS, which was not found in the group of uncontrolled asthmatics. Although ICS has a well-documented effect on airway inflammation, little is known regarding long-term effects on remodeling and mesenchymal cell growth. Effects of steroids on extracellular matrix seem to depend on the nature of the study since Our study shows that tissue composition differs between patients with controlled and uncontrolled asthma on equivalent doses of ICS. Our data support the notion that patients who have remaining symptoms despite conventional ICS therapy have a pronounced matrix remodeling in both central and distal airways and should thus benefit from treatment strategies that target specific inflammatory and remodeling responses in the distal lung. The increased percentage areas of several matrix components and myofibroblasts could be a contributing factor to the persistent symptoms in uncontrolled asthma. Due to the heterogeneity of the disease, asthma medicine needs to be individualized, and new treatments for prevention of remodeling needs to be developed. Currently, several therapies directed at IL-13 are in development . How thoACT: Asthma control test; BAL: Bronchoalveolar lavage; ICS: Inhaled glucocorticosteroids; TGF-β: Transforming growth factor-β; SPT: Skin-prick test; GAG: Glycosaminoglycan; MMP: Matrix metalloproteinase; TIMP: Tissue-inhibitor of matrix metalloproteinase.None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other competing interests to disclose.MW: Contributed to the study design, performed laboratory work, quantified immunostainings, performed statistical analysis, interpreted the data and wrote the manuscript. CA: Contributed to the study design, performed laboratory work, interpreted the data and critically revised the manuscript. AAS: Interpretation of data and revision of the manuscript. ET: Contributed with clinical characterization of the patients, performed MMP-9 ELISA on sputum and revised the manuscript. LB: Recruited patients, collected materials, supervised the study and revised the manuscript. JE and GWT: Contributed to study design, supervised the study, interpreted data and critically revised the manuscript. All authors approved the final version of the manuscript.Online supplementClick here for file


Introduction: Elevated cholesterol and blood pressure are major risk factors for the development diabetic kidney disease. Possible interactions between these two parameters have not been studied in detail. Objectives: This investigation aims to study the values of blood serum cholesterol, blood pressure and possible correlations between them, in a group of type 2 diabetic (T2D) patients. Patients and Methods: A total of 60 patients with T2D were enrolled to the study. Venous blood samples were obtained in the fasting state for determinations of serum creatinine, lipids and hemoglobin A1C (HbA1c). Results: Of 60 participants, Mean of age was 57±8.3 years. Mean of systolic and diastolic blood pressure was 133±13 mmHg and 84±7.4 mmHg respectively. Mean of serum cholesterol and LDL-C was 182±34.5 mg/dl and 97.2 ±27.9 mg/dl respectively. In this study, a significant positive correlation of serum cholesterol with level of diastolic blood pressure  was seen (adjusted for duration of diabetes and weight). Furthermore a significant positive correlation of serum LDL-C with level of diastolic blood pressure  was seen (adjusted for age).Conclusion: We found a significant inverse correlation of serum cholesterol and LDL-C with level of diastolic blood pressure. This study showed the influence of serum lipids on the development of hypertension and further support the control of dyslipidemia, to prevent diabetic kidney disease. In a study on 60 type 2 diabetic (T2D) patients, a significant inverse correlation of serum cholesterol and LDL-C with level of diastolic blood pressure was observed. This study demonstrate the influence of serum lipids on the development of hypertension and further support the strict control of dyslipidemia, as a one of the factors aggravating hypertension and resultant nephropathy.A number of risk factors for nephropathy are known to be present in diabetic patients, the most important being hyperlipidemia . ElevateHypertension is a common condition in diabetes, affecting 20%-60% of patients with diabetes. The presence of high blood pressure and diabetes concomitantly accelerates the renal disease and decrease in renal function and the development of diabetic nephropathy -4. PossiThis investigation aims to study the values of blood serum cholesterol, blood pressure and possible correlations between them, in a group of type 2 diabetic (T2D) patients.A cross-sectional analytical study was carried out in 60 patients with T2D. They were under treatment of oral hypoglycemic agents or insulin therapy. Anthropometric measurements were obtained, including height, weight, Body mass index (BMI) was calculated in kilograms per square meter . Exclusion criteria were cigarette smoking, taking anti lipid drugs. Also patients who were under treatments of antihypertensive drugs or drugs which affects the lipid level or vitamin D metabolism were excluded from the study.The diagnosis of hypertension in people with diabetes is made if the mean of two readings on at least two clinic visits is ≥ 130/80 mmHg. The readings should be verified in the contra lateral arm. Resting systolic blood pressures and fifth phase diastolic blood pressures were measured three times while the subjects were seated, and the second and third measurements were averaged . Patient1c (HbA1c) (reference range 4–6%). Serum LDL-C was calculated by friedewald's formula , low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride measured ) and hemoglobin A formula . Creatin(1) The research followed the tenets of the Declaration of Helsinki; (2) informed consent was obtained; (3) the research was approved by ethical committee of Shahrekord University of Medical Sciences.Results were expressed as mean ± SD and were considered as statistically significant when two-sided p<0.05. Independent-samples t-test was used for comparison variables between male and female. For correlations, partial correlation test was used.1c was 7.4±1.0 %. Mean of serum creatinine was 0.98±0.22 mg/dl. Mean of serum cholesterol and LDL-C was 182±34.5 mg/dl and 97.2 ±27.9 mg/dl respectively. Mean of serum triglyceride and HDL-C was 221±99.1 mg/dl and 42.1 ±7.5 mg/dl respectively. Mean of systolic and diastolic blood pressure was 133±13 mmHg and 84±7.4 mmHg respectively. 1c between males or females. Similarly, no significant difference of systolic or diastolic pressure between males and females was observed. In this study, a significant positive correlation of serum cholesterol with level of diastolic blood pressure  was seen (adjusted for duration of diabetes and weight of the patients). Furthermore, a significant positive correlation of serum LDL-C with level of diastolic blood pressure  was seen (adjusted for age of the patients).There was not significant association between level of systolic pressure with serum cholesterol or LDL-C values (p> 0.05).There was not significant association between serum triglyceride or HDL-C serum values with levels of systolic or diastolic pressure (p> 0.5).Sixty patients were enrolled to the study. Of 60 participants, 56.7% were female. Mean of age was 57±8.3 years. Mean of diabetic duration was 9.2 ±4.9 years. Mean of HbAet al. on lipid profiles of 3,182 uncomplicated non-diabetic patients, an abnormal total cholesterol-HDL ratio as the most common variety of dyslipidemia in uncomplicated hypertension was observed  have been completely observed by the authors.This study was funded by Shahrekord University of Medical Sciences (grant# 898).


Bronchial asthma is frequently accompanied by chronic rhinitis. It has been observed that effective treatment of rhinitis may reduce asthma symptoms. The aim of the study was the evaluation of the control of bronchial asthma symptoms in patients with chronic rhinitis after argon plasma coagulation turbinectomy (APCt). The effect of APCt was assessed in 47 adults with drug-resistant chronic rhinitis and bronchial asthma 3-month post-procedure. Changes of asthma symptoms were scored using Asthma Control Test (ACT). Subjective improvement of nasal congestion 3 months after APCt was observed in 87 % and of rhinorrhoea in 75 % patients. Rhinomanometry showed 219 ± 19 cm³/s increase of flow and 0.75 ± 0.06 Pa/cm³/s reduction of resistance. The prevalence of patients with insufficient bronchial asthma control decreased from 79 to 4 %. The decrease was associated with diminished frequency of eosinophils >20 % in nasal cytology from 83 % pre-procedure to 28 % in the follow-up. The percentage of eosinophils >20 % in cytology before APCt increased the chance for asthma control improvement by 22.8 times. Reduction in symptoms of drug-resistant rhinitis after APCt is followed by significant improvement of asthma control. The most beneficial therapeutic effects of APCt are noted in patients with a high rate of eosinophils in nasal cytology. Results of epidemiological studies suggest an association between bronchial asthma and chronic rhinitis. The recent concept perceives mucous membrane of upper and lower respiratory tract as one entity, affected by inflammatory process, and maintained by common mechanisms. In favour of this concept is the fact that the morphology of the eosinophilic inflammation of the mucous membrane of the upper and lower respiratory tract is similar, and the pathogenesis of both allergic rhinitis and bronchial asthma is triggered and perpetuated by the same factors, such as: allergens, non-steroidal anti-inflammatory drugs (NSAIDs), infectious agents, as well as environmental pollution , 2.Chronic rhinitis affects over 75 % of patients with atopic asthma and about 80 % of those with non-atopic asthma . Their cAlthough surgical treatment does not directly affect the course of allergic reaction, the reduction of inferior nasal turbinate hypertrophy may alleviate the symptoms of allergic rhinitis, through the improvement of local flow disturbances –8.In line with the present view, turbinectomy should be carried out employing methods, which enable maintenance of the physiological function of the mucous membrane after the procedure. Mono-polar argon plasma coagulation (APC), performed without contact between the instrument and the tissue, meets the requirements of modern rhino-surgery. The efficiency and safety of this procedure in reducing hypertrophy of the inferior turbinates have been shown in numerous clinical studies , 9, 10. The aim of this study was the assessment of bronchial asthma symptom control in patients with drug-resistant chronic rhinitis, after argon plasma coagulation of the inferior turbinates.Forty-seven patients  in the age range from 23 to 67 years  with asthma and chronic rhinitis, with symptoms of nasal obstruction caused by hypertrophy of the inferior nasal turbinates diagnosed with first degree of nasal septum deviation in T/S arrangement in rhinoscopy Table ; 11], a, a11], aPatients had persistent symptoms of chronic rhinitis for at least 6 months, resistant to antiallergic medications and intranasal corticosteroids. Self-reported intensity of nasal symptoms  were recorded by patients using a four-point scale  before and after treatment.Patients enrolled to the study were controlled by pulmonologists in the outpatient clinic close to the place of residence, often far from the ENT clinic. Asthma Control Test (ACT) recommended by GINA was applied to assess the course of asthma. The therapy for asthma remained unchanged during the study.Anterior and posterior rhinoscopy, endoscopic examination of nasal cavities and active anterior rhinomanometry in accordance with the recommendations of the Standardisation Committee on Objective Assessment of the Nasal Airway, IRS, and ERS were performed. Following the recommendations, measurements of nasal patency, before and 3 months after conchoplasty, were preceded by a 20-min period of adaptation to laboratory conditions. Throughout the acclimatization time, the patient remained in a sitting position. In each patient, measurements were recorded during five breathing cycles and the mean value was calculated. The values of total flow were analysed and then the total resistance at 150 Pa level was calculated  .Nasal exfoliative cytology samples were obtained by scraping the inferior surface of the inferior turbinate using disposable nasal brushes. Specimens were spread on microscopy slides, fixed in 95 % ethanol and stained with haematoxylin and eosin and Giemsa. Slides were examined using oil immersion light microscopy (1000×). Eosinophil content in swab higher than 20 % was assumed to be characteristic of allergic rhinitis , 14.Bronchial asthma control was assessed on the basis of Asthma Control Test (ACT) Table . The ACTAPCt procedures were performed under local anaesthesia by dressing with 2 % lidocaine solution. Reduction of the lower margins of the inferior nasal turbinate hypertrophy was performed on the entire length of the bottom edge from the rear to the front without contact Fig. , in argoThe initial control visit after APCt was performed after about 7 days post-procedure. In symptomatic patients, the use of intranasal fluticasone furoate was accepted. After a short time, local medication generally was not necessary and was discontinued.The second control examination was performed after 3 months and included rhinoscopy, endoscopic examination of nasal cavities, nasal cytology, rhinomanometry, ACT and self-reported nasal symptoms questionnaire. Smooth, moist and pale pink mucosa on the lower nasal turbinates was revealed on macroscopic evaluation. Local therapy was not used for at least 3 weeks before reassessment. The study protocol did not interfere with asthma medication.χ2 test, U Mann–Whitney test, Wilcoxon’s test. Logistic regression analysis was performed for calculation of the chance of improvement of asthma control after APCt. Odds ratio (OR) was presented with 95 % confidence interval. The value of p < 0.05 was assumed as the threshold of statistical significance.Statistical analysis was performed using the software package Statistica 8 (StatSoft Polska). Results have been presented as average values ± SEM. In statistical analysis, non-parametric tests were applied: Insufficient (score below 20 points) control of asthma before the procedure was found in 37 patients (79 %) and incomplete control (score of 20–24 points) in 10 patients (21 %). Before the APCt, none of the patients declared full control of bronchial asthma according to ACT test (score of 25 points).Before APCt, the average values of total flows and resistance were 201 ± 88 cm³/s and 1.39 ± 0.47 Pa/cm³/s, respectively. Prior to the treatment, nasal stuffiness and rhinorrhoea symptoms were evaluated at 2.6 ± 0.6 and 2.1 ± 0.7 pts, respectively , the nasal cytology revealed the percentage of eosinophils exceeding 20 %.Immediately after the APCt, a zone of superficial coagulation was noticed in the place of plasma application. Within a week, the coagulated tissue was covered with a fibrin coating, while after 1 month linear scars were observed on the lower margins of the inferior nasal turbinates.p < 0.001) improved. The stuffiness score declined from 2.6 ± 0.6 to 1.6 ± 0.7 pts and rhinorrhoea score from 2.1 ± 0.7 to 1.2 ± 0.8 pts post-procedure. The subjective improvement of breathing through the nose was self-reported by 35 out of 47 patients (75 %). Moreover, 34 patients (72 %) reported reduction of the amount of mucoid secretion in nasal cavities and on the posterior wall of the pharynx.Three months after APCt, the average value of total flow increased significantly by 219 ± 19 cm³/s Fig. . Nasal sA significant reduction in the number of patients with the percentage of eosinophils in nasal cytology >20 % from 39 (83 %) to 13 (28 %) in the whole group was observed.In the subgroup of patients with a high percentage of eosinophils in cytology before APCt, remarkably greater increase in total flow (of at least 47 %) in anterior active rhinomanometry was demonstrated  in 32 patients (68 %), incomplete control (score of 20–24 points) in 13 patients (28 %), and insufficient control only in 2 patients (4 %)  than in the subgroup with incomplete asthma control (20–24 points).p = 0.01).Logistic regression analysis showed that the percentage of eosinophils in cytology exceeding 20 % before the procedure significantly increased the chance for the improvement of asthma control level after APCt  Reduction in symptoms of drug-resistant rhinitis after argon plasma coagulation turbinectomy is followed by significant improvement in asthma control. (2) The most beneficial therapeutic effects of argon plasma coagulation turbinectomy are noted in patients with a high rate of eosinophils on nasal cytology. (3) Argon plasma coagulation turbinectomy is a viable method for treating patients with drug-resistant chronic rhinitis and bronchial asthma.


The purpose of this study was to define common carotid blood flow (CBF), cardiovascular and endocrine responses during head-up tilt (HUT) in patients with acute cerebrovascular diseases (CVD). In 31 male patients with acute CVD  and 21 age-matched control male subjects, we measured CBF, mean blood pressure (MBP), heart rate, stroke volume and cardiac output responses before (baseline), during and after HUT. We also measured plasma levels of antidiuretic hormone, adrenaline, noradrenaline, aldosterone and plasma renin activity. After obtaining baseline measurements during 3-minutes horizontal position, HUT was performed for 5 minutes, followed by continuation of recording for 3 more minutes in the horizontal position. During HUT, CBF decreased significantly and equally in both groups. MBP did not change during HUT in both groups. The endocrine responses were also not different between the two groups. The results suggest that damage to the supratentorial area in patients with acute CVD do not alter the CBF, cardiovascular and endocrine responses. In other words, HUT does not predispose patients with acute CVD to serious falls in MBP and CBF at upright posture. Cardiovascular and endocrine responses to head-up tilt (HUT) and the regulation of these responses have been investigated thoroughly in healthy subjects , heart rate (HR), stroke volume (SV), cardiac output (CO), plasma antidiuretic hormone (ADH), adrenaline, noradrenaline, aldosterone and plasma renin activity (PRA) responses during HUT in patients with acute CVD and healthy elderly males. In addition, the Duplex ultrasound system was used to measure CBF and the regional blood flow regulating system.The study included 31 patients with acute CVD who were enrolled in a regular physical therapy program and 21 healthy elderly males as control subjects. The mean age, height, weight and body mass index (BMI) of each group are shown in Table Each subject gave a signed informed consent before participation, and the experimental protocol was approved by the Ethics Committee of Wakayama Medical University.All subjects reported to the laboratory at 4:00 pm on the experiment day. The room temperature was set at 26 ± 0.5°C and all subjects were dressed in cotton underwear. Subjects were also fitted with electrodes for impedance cardiography, and a blood pressure cuff was attached to the unaffected arm of the patients and right arm of the control subjects. The arm was rested at heart level on shelves fastened to the tilt table at any position. HR, SV, CO and CBF were monitored continuously throughout the study, while BP was measured every one minute. After a resting period of 40 min in the supine position on the tilt table, baseline measurements were taken over a 3-min period representing the control period. Subsequently, the tilt table was tilted to 60° within 30 sec and maintained in the HUT position for 5 min as the head-up period. The table was returned within 30 sec to the horizontal position and the subject remained in supine position for 3 min as the recovery period.0)2 T (dZ/dt)min where p is a constant (150 Ωcm), representing blood resistivity at 100 kHz, L is the mean distance between the inner pair of electrodes (cm); Z0 is the basal thoracic impedance (Ω); (dZ/dt)min is the minimal rate of change of impedance (Ω/s); and T is the ventricular ejection time (s) obtained from the dZ/dt waveform. CO was calculated from the product of SV and HR.Impedance cardiography is a noninvasive, highly accurate procedure for continuous monitoring of hemodynamic variables, including HR, SV and CO. This method is useful for measuring SV changes in postural stress. HR and SV were estimated by impedance cardiography , using the standard four-band electrode arrangement  and diastolic blood pressures (DBP) were measured at 1-min intervals by the auscultatory method using a sphygmomanometer on the arm, which was kept still and rested at heart level on the shelf of the tilt table during the head-up period. The MBP was calculated using the formula: MBP = [{(SBP - DBP)/3} + DBP].Extracranial color-coded duplex sonography is a noninvasive, highly accurate procedure for recording hemodynamic data such as blood flow velocity and blood flow volume. The Duplex ultrasound system estimates the flow volume, representing the product of mean flow velocity and the cross-sectional area of the vessel, calculated from the static vessel diameter measured in the B-mode image at the location of the Doppler sample volume. This measurement provides both hemodynamic and morphological information related to brain perfusion. In this study, CBF was measured throughout the study by ultrasonography . The probe was attached to the affected side in acute CVD patients, and to the right side in the control.A 5.1-cm, 20-gauge intravascular over-the-needle catheter with a Luer plug was inserted into the forearm vein. Blood was drawn into ice-chilled tubes containing EDTA at 3, 8, and 11 min into the study, centrifuged (2000 rpm) for 10 min at 4°C, and 5-ml plasma aliquots were stored at -80°C. All samples were assayed for plasma ADH, adrenaline, noradrenaline, aldosterone, and PRA within 2 weeks of sampling.t-test. P values less than 0.05 were accepted as significant. Values are expressed as mean ± SD.The values of each parameter during HUT and recovery period were compared with the baseline by repeated-measures analysis of variance. Multiple comparisons were made using Fisher’s protected least significant difference analysis , SV , CO , MBP  and CBF  between the patients and control subjects. In both groups, HR increased significantly (p < 0.05) during HUT relative to the baseline values, and rapidly returned to the baseline levels after HUT. The magnitude of increase in HR during HUT was not different between the two groups , noradrenaline , ADH , aldosterone  and PRA  between patients and control subjects. Plasma adrenaline and noradrenaline levels increased significantly during HUT in both groups compared with the baseline values (P <0.05), and returned to baseline values during the recovery period. The magnitudes of increase in both hormones in response to HUT were not significantly different between the two groups  MBP did not change during HUT in both the patients and control subjects; 2) CBF decreased during HUT in both groups instead of retention of MBP; and 3) the magnitude of decrease in CBF during HUT was similar in the patients and control subjects. To our knowledge, this is the first study to investigate changes in CBF, neurohumoral balance and cardiovascular responses to HUT in patients with acute CVD.During postural change from supine to upright, blood accumulates in the lower part of the body, particularly in the venous system under gravitational and hydrostatic effects (Hayashi et al. Different to the above findings in acute CVD, previous studies reported that patients with chronic CVD showed immediate fall in BP upon HUT, and the magnitude of such fall in BP was greater than in healthy elderly subjects (Enishi et al. Changes in CBF are often considered representative of changes in cerebral blood flow, although the carotid artery supplies intra- and extra-cranial areas that may not be regulated in the same way (Yoshimoto et al. Adrenaline is released as a circulating endocrine from the adrenal medulla in significant quantities in response to stimulation. The adrenal medulla is innervated by cholinergic sympathetic nerves. In contrast, noradrenaline is a neurotransmitter that leaks from sympathetic nerve terminals into plasma Rowell . It has To adapt to the standing position for a long time, systemic circulating fluid volume and blood volume should remain constant or increase. The most important hormones known to regulate systemic fluid volume released during orthostasis are renin, angiotensins, aldosterone, and ADH Rowell . In the This is the first report of cardiovascular and CBF responses to postural changes in patients with acute CVD. Clinically, it is important to know the changes in BP and CBF during HUT in these patients, because excess falls in BP and CBF during upright posture in these patients have a negative influence on the cerebral circulation. In the present study, upright posture did not induce larger falls in BP and CBF in patients with acute CVD compared with the healthy elderly subjects. Therefore, we believe that the head-up posture is not associated with serious derangement of the mechanisms that control the regulation of BP and CBF in patients with acute CVD.In conclusion, the present study demonstrated a stable MBP and fall in CBF during HUT in patients with acute CVD, and that the magnitude of decrease in CBF was similar in the patient and control groups. Although the supratentorial lesions in acute CVD patients enrolled in the present study did not cover damage of the entire supratentorial area, damage to the supratentorial area in stroke patients seems less likely to alter the MBP and CBF responses induced by upright posture.


Treatment for uncomplicated stage 1 hypertension is recommended in most international guidelines but there is little evidence to indicate that therapy is beneficial.To estimate the prevalence of this condition in an untreated population and the potential costs of initiating therapy in such patients.Cross-sectional study of anonymised patient records in 19 general practices in the West Midlands, UK.Data relating to patient demographics, existing cardiovascular disease (CVD), and risk factors (blood pressure and cholesterol) were extracted from patient records. Patients with a blood pressure of 140/90–159/99 mmHg, no CVD, and <20% 10-year cardiovascular risk were classified as having uncomplicated stage 1 hypertension. Missing data were imputed. The prevalence of untreated, uncomplicated stage 1 hypertension was estimated using descriptive statistics and extrapolated using national data. The cost of achieving blood pressure control in this population was examined in a cost–impact analysis using published costs from previous studies.Of the 34 975 patients (aged 40–74 years) in this study, untreated, uncomplicated stage 1 hypertension was present in 2867 individuals . This is equivalent to 1 892 519 patients in England and Wales, for whom the additional cost of controlling blood pressure, according to guidelines, was estimated at £106–229 million per annum, depending on the health professional delivering care.Untreated, uncomplicated stage 1 hypertension is relatively common, affecting 1 in 12 patients aged 40–74 years in primary care. Current international guidelines and pay-for-performance targets, if followed, will incur significant costs for a patient benefit that is debatable. Hypertension is a key risk factor for the development of cardiovascular disease (CVD),13The treatment of uncomplicated  stage 1 hypertension (sustained blood pressure of 140/90–159/99 mmHg) has long been considered controversial due to the paucity of evidence to support such a strategy.12The impact of these recommendations on clinical practice is unclear. Although the prevalence of hypertension is well documented across the world,29demographic information;cardiovascular risk-factor details; andall cholesterol and blood pressure lowering medication prescribed within the 90 days prior to the query date.A cross-sectional retrospective study of anonymised, primary care medical records was conducted in 19 general practices across the West Midlands, UK. The methods of data collection have been detailed elsewhere.There are varying recommendations on how to treat people with uncomplicated stage 1 hypertension, but many guidelines recommend therapy for all whose blood pressure is ≥140/90 mmHg, despite the lack of robust clinical trial evidence supporting treatment. At least 1 in 12 patients aged 40–74 years old have the condition but receive no treatment for it. The cost of initiating treatment in these individuals in England and Wales in line with current international guidelines, would be substantial (£106–229 million: US$180–389 million and €134–289 million) in the first year, but the benefits for patients are unknown.This study focused on individuals aged 40–74 years, as younger people require further assessment for secondary causes of hypertension before treatment is administeredThis study aimed to establish the prevalence of untreated, uncomplicated stage 1 hypertension. As such, patients with no blood pressure reading from the preceding 5 years, those with existing CVD, or those already receiving blood pressure or cholesterol-lowering therapy were not considered in this analysis; it was assumed that patients receiving blood pressure- or cholesterol-lowering therapy had been at high risk of CVD prior to initiation.Given that the classification of hypertension was based on only the most recent clinic blood pressure reading, the prevalence of stage 1 hypertension was adjusted to account for the 56% positive predictive value (PPV) of clinic blood pressure measurements around the diagnostic threshold for hypertension.Where possible, data on cardiovascular risk factors were used to estimate CVD risk using the Framingham equation.The potential costs of treating uncomplicated stage 1 hypertension were examined in a cost–impact analysis using the methodology utilised by NICE for the development of costing tools to assist the implementation of new guidance.The level of new activity generated by guideline implementation was defined in the present study as the number of drugs required to control blood pressure to <140/90 mmHg in each patient and the health professional’s time incurred when prescribing and monitoring the treatment regimen. These figures were estimated using data from the Hypertension Optimal Treatment trial.12NHS Electronic Drug TariffUnit Costs of Health and Social Care 201218The costs of resource utilisation were estimated using the 2 tests.Descriptive statistics were used to define the proportion of patients in each group with different levels of blood pressure control . Data are presented according to age (40–54 years and 55–74 years) and sex; comparisons were made using χThe number of people with untreated, uncomplicated stage 1 hypertension in the population of England and Wales was estimated by extrapolating from the local prevalence estimates derived from this study to national population data.Of the 90 516 patients registered at participating practices, 34 975 were aged 40–74 years and could have been included in this analysis; however, of these, 2550 (7.3%) patients had existing CVD, 7406 (21.2%) were already on treatment, and 4764 (13.6%) had no clinic blood pressure readings in the preceding 5 years from the data extraction date. Of the remaining 20 255 patients (57.9%), 4985 (14.3%) had total and HDL cholesterol information available to calculate CVD risk, leaving 15 270 (43.7%) where cholesterol was imputed. Diabetes, chronic kidney disease, and ischaemic heart disease were the most common comorbidities .P<0.001) and females , reflecting an increased risk of CVD in older patients and males. 34A total of 12 647 patients had hypertension, of which 4421 patients (35.0%) were not receiving antihypertensive treatment. In patients receiving no treatment, stage 1 hypertension was present in 3321 individuals , of whom 2867  had low CVD risk . Untreated, uncomplicated stage 1 hypertension was more common in younger patients .Initiation of therapy in such patients is not recommended (by guidelines) in the UK but many international guidelines do recommend therapy in this group,This study used routine data from the West Midlands, UK, and included all registered patients aged 40–74 years from a large cohort of general practices. These data were comparable with the national population aged 35–74 years, in terms of mean age and sex,Data used here were collected in 2008 and 2009 but the researchers are confident that the prevalence estimates are still relevant today. According to figures from the Quality and Outcomes Framework (QOF),33The estimates of the prevalence of untreated, uncomplicated stage 1 hypertension presented here may be conservative: patients without a blood pressure reading in the 5 years prior to the study were assumed to not have stage 1 hypertension. Where it was recorded, no correction was made for blood pressure measurement error in patients with stage 2–3 hypertension due to uncertainty about the PPV of readings taken around the 160/100 mmHg threshold. In practice, there is likely to be a degree of measurement error, resulting in some patients with stage 1 hypertension being classed as having stage 2–3 hypertension and vice versa. The Framingham equation may overestimate risk, resulting in the misclassification of individuals (as high risk) and reducing our estimate of the prevalence of uncomplicated stage 1 hypertension;35The assessments of CVD risk undertaken were limited to evaluating existing CVD and CVD risk score; target organ damage, and diabetes were not considered separately, although the latter was included in the Framingham risk equation used here.Finally, an assumption was made that there are no long-term benefits from the treatment of uncomplicated stage 1 hypertension, in terms of potential cost savings based on the Cochrane Review findings.To the authors’ knowledge, this is the first study to document the community prevalence of untreated, uncomplicated stage 1 hypertension anywhere in the world. The prevalence of hypertension in international surveys varies by method of diagnosis, and between countries and continents, from 23.0% to 46.0%26et al,This study found that 1 in 12 patients aged 40–74 years have untreated, uncomplicated stage 1 hypertension. The cost of a strategy to treat these patients in clinical practice was estimated to fall between £106 million and £229 million (US$180–389 million or €134–289 million). Whether to initiate treatment in patients with uncomplicated stage 1 hypertension is a source of much debate.The Canadian Hypertension Education Program guidelines4The European Society of Hypertension (ESH) guidelinesThe Eighth Joint National Committee guidelinesSince the publication of the Cochrane Review,The data presented here do not suggest that therapy to reduce blood pressure in those with low CVD risk and stage 1 hypertension would provide an adequate cost–benefit ratio, given the high NNT and costs in order to prevent one vascular event, along with the potential adverse consequences an individual may experience having been labelled as having hypertension through side effects and labelling.46Untreated, uncomplicated stage 1 hypertension is common, affecting at least 8.2% of the population aged 40–74 years in England and Wales. International guidelines