Hypertensive emergency has a high mortality risk and the treatment goal is to quickly lower blood pressure with intravenous (IV) medications. Characteristics that are associated with non-response to IV antihypertensives have not been identified. The objective is to identify patient characteristics associated with resistance to IV antihypertensives.This was a subanalysis of patients enrolled in the previously described comparative effectiveness trial of IV nicardipine vs. labetalol use in the emergency department (CLUE) study, a randomized trial of nicardipine vs. labetalol. Non-responders were defined as those patients who did not achieve target systolic blood pressure (SBP), as set by the treating physician, within thirty minutes of IV antihypertensive medication, +/− 20mmHg. Stepwise logistic regression was used to identify covariates associated with the measurement outcomes.CLUE enrolled 226 patients, 52.7% female, 76.4% black, mean age of 52.6±14.6 years, of whom 110 were treated with nicardipine and 116 with labetalol. The median (IQR) initial systolic blood pressure was 211mmHg , 210 , and 211mmHg , for the total, non-responder, and responder cohorts, respectively . Twenty-nine were non-responders, 9 in the nicardipine and 20 in the labetalol group. In univariate analysis, several symptoms suggestive of end organ damage were associated with non-response. After multiple variable logistic regression (AUC = 0.72), treatment with labetalol , history of stroke , and being male  were associated with failure to achieve target blood pressure.Male gender and history of previous stroke are associated with difficult to control blood pressure. Hypertension, defined as a blood pressure of greater than 140/90mmHg, affects almost one fourth of the adult U.S. population.2The frequency of hospitalizations for a hypertensive emergency increased from 101/100,000 U.S. adults in 2000 to 111/100,000 U.S. adults in 2007, an average increase of about 1.1% over the seven year time period.7a priori identification of patients that may be resistant to initial treatments would be helpful to identify those whom would benefit from a more aggressive approach, such as more rapid titration or early addition of a second agent. Identifying patients who may need prolonged IV antihypertensive therapy is important because it allows for appropriate disposition and monitoring of the patient. Patients receiving prolonged IV antihypertensive medications require close clinical monitoring to avoid overshooting target blood pressure and other significant hemodynamic consequences. The objective of this analysis is to identify characteristics of those patients resistant to parenteral antihypertensives for the treatment of hypertensive crisis in the emergency department (ED).It has long been recognized that overly aggressive lowering of blood pressure can be harmful, and even catastrophic in some cases. Therefore, ClinicalTrials.gov with identifier NCT00765648.This study is a descriptive sub-analysis of the multicenter Evaluation of IV Cardene (Nicardipine) and labetalol use in the emergency department (CLUE) trial, a U.S.-based, prospective, randomized, open-label study of the management and outcomes for patients with acute severe hypertension treated with IV antihypertensive therapy in the emergency department.Adult patients (aged ≥18 yrs) who presented to one of 13 participating hospitals’ emergency departments with acute severe hypertension were eligible for inclusion. Patients provided written informed consent, including authorization to use protected health information, for inclusion into the study. Acute severe hypertension was defined as two consecutive systolic blood pressure readings, at least ten minutes apart, of 180mmHg or greater.Patients were ineligible if they had specific contraindications to receiving either a beta blocker or a calcium channel blocker. Patients were also excluded if they met any of the following criteria: use of any investigational drug within 30 days, pregnant or breast-feeding, contraindications or allergy to beta-blockers and calcium channel blockers , advanced aortic stenosis, bronchial asthma, overt cardiac failure, greater than first-degree heart block, cardiogenic shock, severe bradycardia, obstructive airway disease, decompensated heart failure or a known left ventricular ejection fraction <35%, history of stroke within 30 days, known impaired hepatic function, suspected myocardial infarction (MI), suspected aortic dissection, suspected cocaine use as the cause of ED presentation, or if they were concurrently receiving any IV antihypertensive medication.After obtaining informed written consent, the treating physician was asked to define a target systolic blood pressure with a range of ± 20mmHg prior to patients being randomized to IV labetalol or nicardipine per set protocol.Blood pressure recordings were taken with an automatic cuff every five minutes during the 30 minutes following initiation of treatment. Vital signs and adverse events were also monitored for six hours after initiation of IV antihypertensive or until discharge from the ED, whichever came first. The presence of end organ damage was also recorded. End organ damage was defined as having any one of the following symptoms suggestive of a hypertensive emergency at time of presentation: chest pain, shortness of breath, epigastric discomfort, syncope, dizziness, blurred vision, diplopia, diminished level of consciousness, confusion, hematuria, or development of acute ischemic changes on a twelve lead electrocardiogram. Although not all of these symptoms are included in the traditional definition for hypertensive emergency, the study group wanted to ensure that it captured patients with atypical symptoms for acute coronary syndrome. For this subanalysis, patients who met the target blood pressure (BP) within 30 minutes were defined as responders and those who did not meet target BP were defined as non-responders.Categorical variables were compared by using Chi-square or Fisher’s Exact test, and continuous variables by Student’s T-test or Wilcoxon rank-sum test if the variable was not normally distributed. A multivariable logistic model to assess the risk factors for non-responders within 30 minutes, after controlling for site differences, was developed. Missing values were not imputed and only observed values were used for the multivariable analyses. All baseline variables with no more than 10% missing data points were considered for inclusion into the adjusted model. A stepwise elimination procedure was used to determine the final model. Risk factors with univariate p-value ≤0.10 were considered and included in the stepwise elimination procedure. All variables with a p-value <0.05 were included in the final model. The final multivariable logistic model included the variables of treatment drug, gender and no history of stroke. All statistical analyses were performed using SAS version 9.2 .A total of 226 patients were enrolled in the initial trial, 109 (49%) in the nicardipine group and 114 (51%) in the labetalol group . One patPresenting vital signs were similar throughout all subpopulations. The median (IQR) initial systolic blood pressure was 211mmHg , 210 , and 211mmHg , for the total, non-responder, and responder cohorts. Further, the minimum to maximum range of presenting systolic blood pressure was 163 to 275, 184 to 264, and 163 to 275mmHg for the total, non-responder, and responder populations. Finally, the mean initial presenting heart rate varied by approximately 1 beats per minute (bpm) for all cohorts .Non-responders were more likely to be male. They were also more likely to have previous medical history of stroke. Further, being a non-responder was associated with an altered level of consciousness, epigastric discomfort or palpitations at presentation. Non-responders were less likely to be taking antiadrenergic medications . An elevAs expected, non-responders spent less time in the pre-specified target BP range than responders. In fact, non-responders clearly represented a cohort of extremely resistant hypertensive patients as none were noted to have a BP reading within the target range during the entire thirty minute period. This compared to responders who had a median of 4 out of 6 BP readings within the target range . Only onAlthough responders and non-responders were noted to have medication titrated the same amount of times within the thirty minute study period, responders received less drug overall due to smaller doses required to achieve blood pressure control within 30 minutes. Despite higher overall doses, non-responders had a significantly lower percent change in systolic blood pressure when compared to responders . With reAfter adjusting for significant baseline variables by multivariate logistic regression, including forcing the study site into the model, randomization to treatment with labetalol , having a past medical history of stroke , or being male  were independently associated with failure to achieve a systolic blood pressure in the target range within 30 minutes of the start of IV anti-hypertension therapy .The primary goal of the CLUE study was to determine whether there was a difference in achieving target blood pressure within thirty minutes using nicardipine vs. labetalol. To the best of our knowledge, patient characteristics that are associated with resistance to parenteral antihypertensives in the ED have not been previously described. If patients resistant to BP control can be identified at presentation, more aggressive ED therapy may prevent further complications. Early ED identification of patients who will predictably have a poor response to BP control interventions may also assist emergency physicians in making appropriate inpatient dispositions decisions. Our univariate analysis suggests that presenting with select symptoms suggestive of end organ damage, including altered level of consciousness, epigastric pain and palpitations, increases the likelihood that blood pressure will not be lowered to target level within thirty minutes of treatment initiation. Our multivariate analysis indicates that being male and having history of a previous stroke also increases that likelihood.The overall prevalence of hypertension is relatively similar between men and women, although men have a higher prevalence below the age of 60, and women have the higher prevalence after age 60.Hayes and Taler reviewed the literature regarding gender differences in chronic HTN to determine if treatment options for women should be different than those for men.14There are multiple physiologic differences between males and females that may contribute to development of hypertension, many of which disappear after menopause. These differences include higher cardiac index, higher HR and lower peripheral resistance and blood volume.History of a prior stroke is an intuitive factor affecting acute blood pressure control since the brain plays a key role in regulation of blood pressure. It has been shown that blood pressure rises in the first 24 hours after stroke to increase perfusion to the damaged area of the brain.End organ damage will also intuitively lead to difficulty controlling blood pressure, as injury to the brain and kidneys affect the regulation of blood pressure. Persistence of elevated blood pressure leads to endothelial damage, promoting platelet aggregation and fibrin deposition, which stimulates release of further inflammatory molecules and perpetuates cycle of damage.There are multiple studies to guide choice of IV antihypertensive in the setting of specific end organ damage such as stroke, MI, aortic dissection and end stage renal disease, but no recommendation for an IV antihypertensive that could be started based on suspicion alone of end organ damage.There are a number of limitations to our study. First, we used only two IV antihypertensives, so patients labeled as non-responders are not necessarily unresponsive to all IV antihypertensives. We chose a two medication study model because it allowed direct comparison of two of the most common classes of IV antihypertensives currently used in U.S. emergency departments and there is no gold standard medication for blood pressure control. The selected agents were relatively easy to titrate with a low side effect profile. However, there are differences in the method of administration between labetalol and nicardipine (bolus vs. infusion) that may account for our results, in that an infusion may inherently reach the target BP range faster than bolus therapy. Our study was not designed to determine the effects of administration method on time to BP control.Secondly, the treating physicians had control over multiple variables. FDA recommendations are for titration of the nicardipine at intervals of 5 minutes, while the labetalol is re-dosed at 10 minute intervals. However, the actual titration intervals and dosing were left to the discretion of the treating physician, which may have biased the study. It is possible that more aggressive dosing of the medications might have altered results. Importantly, there were no differences in the number of times the two drugs were titrated, although there were more non-responders in the labetalol group. The treating physicians also set the goal blood pressure. Common recommendations for hypertensive emergency call for lowering the blood pressure by 25% over hours. However, there are individual patient characteristics that may affect the timing and degree of lowering. Allowing the treating physicians to set the blood pressure goal reflects real world practice.Thirdly, as this was a randomized controlled trial, the groups were similar in terms of baseline characteristics. However, the treating physicians were not blinded to study drug and therefore bias may have been introduced with regard to the effect of allocated treatments. Due to the low number of patients that were defined as non-responders, there was a limited amount of covariates that could be analyzed and there may be further factors that are associated with nonresponse that we failed to identify.Using systolic blood pressure alone may have failed to identify patients with isolated elevated diastolic blood pressure who may be at risk for hypertensive emergency. It is unclear if those patients would have a different response to medication therapy. It was acknowledged by JNC 7 that diastolic pressure levels out and may actually fall after the age of 50, making systolic blood pressure a more potent cardiovascular risk factor in patients over the age of 50.Finally, CLUE only reported BP response within the first 30 minutes of antihypertensive use. It is unknown if those patients that were resistant within this time period continued to be resistant, or if it just took longer for them to respond. However, it can be argued that BP control requiring more than 30 minutes to attain is insufficient in the setting of hypertensive emergency. Labetalol has an onset of action of just five minutes and a peak effect is reached by thirty minutes. Nicardipine has an onset of action within 5–15 minutes, although the peak effect is not reached until about 45 minutes. This knowledge would suggest that a longer time period may be needed to assess non-response to nicardipine, but this study found more non-responders in the labetalol group.In this secondary analysis from the CLUE study, we have identified patient characteristics associated with difficulty in the emergency department control of BP within 30 minutes of the initiation of therapy. These characteristics include being male and having a previous history of stroke.


Orthostatic dizziness without orthostatic hypotension is common but underlying pathophysiology is poorly understood. This study describes orthostatic cerebral hypoperfusion syndrome (OCHOs). OCHOs is defined by (1) abnormal orthostatic drop of cerebral blood flow velocity (CBFv) during the tilt test and (2) absence of orthostatic hypotension, arrhythmia, vascular abnormalities, or other causes of abnormal orthostatic CBFv.2, blood pressure, and CBFv from the middle cerebral artery using transcranial Doppler. Patients were screened for OCHOs. Patients who fulfilled the OCHOs criteria were compared to age- and gender-matched controls.This retrospective study included patients referred for evaluation of unexplained orthostatic dizziness. Patients underwent standardized autonomic testing, including 10 min of tilt test. The following signals were monitored: heart rate, end tidal COp < 0.0001) without orthostatic hypotension in both groups. Supine mean blood pressure  remained unchanged during the tilt . End tidal CO2 and heart rate responses to the tilt were normal and equal in both groups.From 1279 screened patients, 102 patients  fulfilled criteria of OCHOs. There was no difference in baseline supine hemodynamic variables between OCHOs and the control group. During the tilt, mean CBFv decreased 24.1 ± 8.2% in OCHOs versus 4.2 ± 5.6% in controls (OCHOs is a novel syndrome of low orthostatic CBFv. Two main pathophysiological mechanisms are proposed, including active cerebral vasoconstriction and passive increase of peripheral venous compliance. OCHOs may be a common cause of orthostatic dizziness. Orthostatic dizziness is common, affecting 2–19% of elderly  Novak,  grades aThe study was approved by the Institutional Review Board of the University of Massachusetts Medical School as a minimal risk study and the consent form signature was waived.This retrospective, single-center study included consecutive patients who underwent autonomic testing between 2008 and 2014 at the University of Massachusetts Medical School Autonomic laboratory. The inclusion criteria were: (1) history of orthostatic symptoms, including dizziness, weakness, fatigue, visual blurring, vertigo, suboccipital, paracervical or chest pain, headaches, dyspnea, palpitations, and low back pain  and CBFv in the middle cerebral artery using Transcranial Doppler. Baseline supine blood pressure was obtained intermittently using an automated oscillometric blood pressure device Dinamap ProCare Monitor 100  from arm and continuously (beat-to-beat) using Finometer®  from the third finger. During the tilt test, blood pressure was obtained every minute using the Dinamap ProCare device and continuously using Finometer®. The Dinamap obtained blood pressure served as a reference for the Finometer-based blood pressure. Finometer-based blood pressure was calibrated with the Dinamap-based blood pressure.All testing was performed following established standards Low,  and was The temporal acoustic window with a 2 MHz probe was used for acquisition of CBFv using a MultiDop T . The left middle cerebral artery has been identified at an insonation depth from 45 to 65 mm. After the optimal flow signal has been detected, transducer has been attached to head with a plastic head frame with a three-dimensional positioner to maintain a tight transducer fixation at constant depth and angle of insonation. Continuous Trancranial Doppler monitoring has been performed during the supine baseline period and the tilt. Signals were recorded using LabChart 7 system  and sampled at 400 Hz.Normative data for CBFv at both supine and tilt test are age, gender, and the tilt duration dependent. In healthy subjects, the CBFv is either unchanged or there can be a mild drop in CBFv during the tilt. The criteria for normal drop of the mean CBFv during tilt test are equal to 90/% (1st minute), 89% (5th minute), and 85% (10th minute) of the tilt where baseline is equal to 100% Novak, .Instantaneous heart rate, systolic, mean, diastolic blood pressure, and CBFv were obtained on beat-to-beat basis. Resistance index (RI) and cerebral vascular resistance  symptoms that occur during the upright position and are relieved at supine and (2) symptoms should be present without any body movement, both in the supine and upright position. The symptoms include dizziness, lightheadedness, visual disturbances, hearing disturbances, vertigo, fatigue, sweating, weakness, headache, neck pain, chest pain, palpitations, confusion, agitation, memory problems, and inattentiveness  abnormal orthostatic drop of mean CBFv fulfilling criteria of at least moderate abnormality on the QASAT-CBF  presence of orthostatic hypotension (QASAT section 7 > 0); (2) presence of arrhythmia defined as presence of bradycardia during supine or tilt test (QASAT section 1 > 0) or tachycardia during the tilt test (QASAT section 3 > 1). This criterion also excludes postural tachycardia syndrome (POTS)  was used to test differences between the OCHOs and non-OCHOs patients at baseline, 1st minute, 5th minute, and 10th minute of tilt. The initial significance level (α) has been set to 0.05. Since there were four comparisons, the Bonferroni-corrected significance level was adjusted to 0.0125 (obtained by 0.05/4). The effect of tilt within group was analyzed by MANOVA for repeated measures. JMP 12  statistical software was used for all statistical analyses.n, disease duration ] 21, 5.9 ± 3.4, migraine 14, 5.1 ± 3.4, bipolar disorder , polyneuropathy , dyslipidemia , diabetes , fibromyalgia , autonomic neuropathy , Parkinson disease , hypothyroidism , chronic fatigue syndrome , anxiety , and connective tissue disorder .From 1279 patients who were referred for evaluation of unexplained orthostatic dizziness, 102 patients satisfied criteria for diagnosis of OCHOs. These patients were age- and gender-matched with the same number of control subjects with normal responses to tilt. Table Figure Comparing OCHOs and controls, there was no difference in all tested variables during the supine period before the tilt Table . Both grp < 0.0001, Table 2 during baseline supine and during the tilt compared both groups.In most subjects, there was a progressive drop of systolic, mean, and diastolic CBFv’s in both groups during the tilt test Table –3. In se2 (p < 0.0001), mean CBFv (p < 0.0001), and heart rate (p < 0.0001) but not on systolic/mean/diastolic blood pressure at p = 0.05 level at both groups.MANOVA for repeated measures showed significant effect of tilt upon end tidal COAll subjects with OCHOs and none of the control subjects had orthostatic symptoms during the tilt test.Orthostatic cerebral hypoperfusion syndrome is a novel syndrome associated with orthostatic hypoperfusion. OCHOs patients have stable orthostatic blood pressure, heart rate, and respiratory pattern and they still have reduced orthostatic CBFv. A decrease in orthostatic CBFv may produce cerebral hypoperfusion and central nervous system symptoms, including dizziness . Whether this is real association between hypertension and OCHOs or it reflects referral bias needs to be assessed in further studies.There are several mechanisms that may lead to cerebral hypoperfusion in OCHOs. Cerebral perfusion is controlled by a complex system called cerebral autoregulation that determines relationship between CBFv and the blood pressure. CBFv is kept constant within relatively large variations of the blood pressure by adjusting the vascular resistance. Static autoregulation determines the average CBFv at a given blood pressure under steady-state conditions. Then low CBFv with stable orthostatic blood pressure and heart rate indicates failure of cerebral autoregulation such as the static cerebral autoregulation is reduced. The mechanism associated with the autoregulatory failure in OCHOs can be abnormal vasoconstriction at the cerebral arterioles that reduces the cerebral flow. Cerebral vasoconstriction was proposed as underlying mechanism for reduced orthostatic CBFv in healthy subjects and in orthostatic tachycardia syndrome  , OH , and OCHOs . Using an orthostatic triad  classification can set up a useful clinical framework for evaluation of orthostatic symptoms. To evaluate patients using the outlined classification, it is essential to monitor CBFv in addition to heart rate, blood pressure, and respiratory variables during the tilt test.Results presented in this paper may have direct clinical significance. The concept of OCHOs provides physiologically plausible mechanism for unexplained orthostatic dizziness that is very common. The proposed concept of OCHOs relies on inexpensive technology  and normative data are provided.This study has several limitations. The principal limitation is its retrospective character where the OCHOs criteria were applied to already acquired data and the exact criteria may not be applicable to other population. Second, a referral bias may affect selection of subjects and, therefore, the studied population may not be representative. Third, a bias could be introduced by using the particular transcranial Doppler device since the CBFv values may be device dependent Novak, . Fourth,In conclusion, OCHOs may be a common cause of orthostatic dizziness in patients without orthostatic hypotension. Orthostatic dizziness in OCHOs is consistent with central nervous system hypoperfusion due to low orthostatic CBFv with a failure of static cerebral autoregulation most likely due excessive cerebral vasoconstriction upon upright posture. Detection of OCHOs is straightforward by simultaneous monitoring of hemodynamic variables and CBFv during the tilt test.PN designed the study, participated in data collection, performed data analysis, and wrote the manuscript.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewers, TP and BM, and handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.


Low-dose spironolactone has been proven to be effective for resistant hypertension in the general population, but this has yet to be confirmed in type 2 diabetic (T2DM) patients. We assessed the efficacy of a low-dose spironolactone on resistant hypertension in a sub-Saharan African population of T2DM patients from Cameroon.This was a four-week single blinded randomized controlled trial in 17 subjects presenting with resistant hypertension in specialized diabetes care units in Cameroon. They were randomly assigned to treatment with a daily 25 mg of spironolactone (n = 9) or to an alternative antihypertensive regimen (n = 8), on top of any ongoing regimen and prevailing lifestyle prescriptions. They were seen at the start of the treatment, then 2 and 4 weeks later. The primary outcome was change in office and self-measured blood pressure (BP) during follow-up, and secondary outcomes were changes in serum potassium, sodium, and creatinine levels.p = 0.024), and in diastolic BP . After 1 month of spironolactone, all the patients were controlled based on BP below 130/80 mmHg, with significant office BP reduction from 158 ± 17/86 ± 11 to 125 ± 11/72 ± 8, vs. 158 ± 8/94 ± 8 to 144 ± 17/89 ± 12 mmHg in the alternative treatment group. There was no significant variation in sodium and creatinine levels in both groups, but a mild increase of potassium levels in the spironolactone group.Compared with alternative treatment, low-dose spironolactone was associated with significant decrease in office systolic BP (−33 vs. −14 mmHg; Add-on low-dose spironolactone was effective in reducing BP to optimal levels in T2DM Cameroonian patients despite mild increase in serum potassium.Trial registration ClinicalTrials.gov Identifier NCT02426099. Date of registration April 2015 Hypertension and diabetes have reached epidemic proportions worldwide, fuelling a burden of cardiovascular disease. It is estimated that at least 1 billion adults have hypertension globally, a figure that is projected to increase to 1.5 billion by 2025 . CoexistBlood pressure (BP) control is a huge challenge in diabetic patients, especially those of African ancestry. To date, there is a general consensus on angiotensin converting enzyme (ACE) inhibitors as first-line treatment for hypertension in diabetic subjects. Diuretics, B blockers and calcium channel blockers (CCB) can be added as second or third-line treatment to reach the target BP objectives. The choice of these drugs generally takes account of existing cofactors or indications . More thThe prevalence of resistant hypertension is estimated at 10–15 % in all patients treated with antihypertensive depending on definition and study population –12. It iThe study protocol was approved by the National Research Ethics Committee for Human Health of Cameroon . Written informed consent was obtained from all participants. The study was conducted in accordance with the Helsinki Declaration.NCT02426099. A protocol was developed during the planning process.This project was retrospectively registered on ClinicalTrials.gov in April 2015. It was a prospective randomized controlled single blinded trial conducted over a six-month period from October 2011 to March 2012. There was no change in protocol during the study.2 of body weight, absolute contraindication to any of the drug regimen of the trial, and current aldosterone antagonist treatment or cessation within the last 15 months.The reference population comprised diabetic patients aged <75 years presenting with a resistant hypertension of unknown etiology at the outpatient clinics of the National Obesity Center and of the Diabetes Care and Education Center of the Yaoundé Central Hospital, as well as those participating in an ongoing study on glycated hemoglobin (HbA1c). Resistant hypertension was defined as an office BP value ≥140/90 mmHg and self-blood pressure measurement (SBPM) ≥130/80 mmHg under at least three antihypertensive drugs at optimal dosages for at least two months, including a diuretic , blood urea nitrogen (BUN) and proteinuria. All biochemical measurements were done at baseline and serum sodium, potassium and creatinine levels were checked again during visits.2) was calculated as ® Compact Plus glucometer . Unfortunately aldosterone was not measured in this study.Office BP and self-blood pressure measurement (SBPM) were considered at every visit. For office BP, three serial measurements taken 5 min apart in the sitting position were obtained from the left arm placed at the level of the heart, using an automated sphygmomanometer Omron HEM-705 CP . The average of the second and third measurements was used for all analyses. The daytime SBPM considered was the mean of BP values self-recorded at home in the same condition than those applied in clinic three consecutive days prior to the visit, without health personnel. ECG was recorded using the CardiMax FX-7302 electrocardiograph . Weight was measured in light clothed subjects to the nearest 0.5 kg with a mechanical scale; height was measured in the upright position to the nearest 0.5 cm, and body mass index  and 5 % risk of error (α) a minimal relevant difference (δ) of 20 (SD 4) mmHg  for the p value <0.05 was considered statistically significant.Data were analyzed based on the intention to treat principle, using IBM SPSS for Windows, version 20.0 . Continuous variables are expressed as means with standard deviation (SD), and categorical variables as count (percentage). Non parametric Mann–Whitney tests were used to compare continuous variables. A Out of the 672 diabetic patients received at the enrolment centers between October 2011 and March 2012, 377 (56.1 %) were hypertensive; of whom 49 (13 %) had a diagnosis of resistant hypertension were screened for eligibility. After exclusion of ineligible subjects, 17 patients were definitively randomized. None of the participants left the trial, and all of them were included in the intention-to-treat analysis. There was a good compliance to treatment and no change in medications occurred during the follow up. The trial profile is outlined in Fig. 2 , nor for SBPM [end-of-trial mean BP (mmHg) = 142 ± 14/86 ± 14]. Only two out of eight participants in the control group reached the target control BP levels.The mean change in office and self-measured systolic and diastolic BP at the end of the trial is presented in Table The mean serum potassium was mildly increased from 4.02 to 4.38 mmol/L in the spironolactone group after 4 weeks  was higher than the 12/7 mmHg reported by olactone . The morolactone , BP redu therapy . These r therapy , 32.Oxlund et al. [Unlike participants in our alternative drug regimen group, all those in the spironolactone group reached the target office BP of 130/80 mmHg recommended by the IDF , with thd et al. , only 36d et al.  like ourd et al. , and stiMakhlough et al. also proved that a low dose spironolactone used alone was as effective as spironolactone-losartan combination in improving on the diabetic nephropathy [Recent studies in animals and humans, have reported that spironolactone produces many other metabolic benefits (preventing dyslipidemia) and cardiovascular effects in T2DM, beside its known diuretic properties , 16, 29.hropathy . These ahropathy , since thropathy , 35.Despite the safe dosage of spironolactone used in this study, we observed a mild increase in mean serum potassium levels in the spironolactone group. Even though severe hyperkalemia was noted in two subjects at the end of the study, this was likely driven by their high initial level of serum potassium level. Of note, all those patients had CKD, which is associated with high risk of hyperkalemia . FurtherOur study is mostly limited by the small sample size, limiting our ability to generate stable estimates or to perform post hoc subgroups analyses. More adequately powered trials with extended follow-up are needed to draw definitive conclusions. Indeed, since hypertension is a chronic disease, the benefit of low-dose spironolactone in long term treatment of resistant hypertension still needs to be demonstrated.This trial has shown that a low-dose (25 mg) of spironolactone as an add-on therapy for resistant hypertension among Black Africans with T2DM was associated with a significant reduction of the office and self-measured BP to optimal levels after 1 month of treatment, without affecting sodium level, but with mild elevation of serum potassium.


Recent genome-wide association studies have identified 33 human genetic loci that influence blood pressure. The 15q24 locus is one such locus that has been confirmed in Asians and Europeans. There are 21 genes in the locus within a 1-Mb boundary, but a functional link of these genes to blood pressure has not been reported. We aimed to identify a causative gene for blood pressure change in the 15q24 locus.CSK and ULK3 were selected as candidate genes based on eQTL analysis studies that showed the association between gene transcript levels and the lead SNP (rs1378942). Injection of siRNAs for mouse homologs Csk, Ulk3, and Cyp1a2 (negative control) showed reduced target gene mRNA levels in vivo. However, Csk siRNA only increased blood pressure while Ulk3 and Cyp1a2 siRNA did not change it. Further, blood pressure in Csk+/- heterozygotes was higher than in wild-type, consistent with what we observed in Csk siRNA-injected mice. We confirmed that haploinsufficiency of Csk increased the active form of Src in Csk+/- mice aorta. We also showed that inhibition of Src by PP2, a Src inhibitor decreased high blood pressure in Csk+/- mice and the active Src in Csk+/- mice aorta and in Csk knock-down vascular smooth muscle cells, suggesting blood pressure regulation by Csk through Src.Csk is a causative gene in the 15q24 locus and regulates blood pressure through Src, and these findings provide a novel therapeutic target for the treatment of hypertension.Our study demonstrates that  Blood pressure is influenced by a variety of mechanisms that involve many genetic factors. To detect genetic markers for blood pressure, genome-wide association studies (GWASs) have been performed using large human samples from various ethnic groups and have identified many genetic loci that are associated with blood pressure and hypertension. The Korean Association REsource (KARE) , the GloP = 2×10−6 with systolic blood pressure (SBP), P = 6×10−8 with diastolic blood pressure (DBP), N = 34,433 Europeans), the CHARGE consortium .–13.CSK  were examined for blood pressure change in siRNA-injected mice after testing for in vivo silencing by siRNAs injection. We showed that only Csk siRNA injection increased blood pressure while Ulk3 and Cyp1a2 siRNA injections did not change it. Our results along with the eQTL analysis indicate that CSK is a causative gene in the 15q24 locus. We also confirmed that haploinsufficiency of Csk increased blood pressure in Csk+/- heterozygote mice compared to the wild-type. Further, inhibition of Src, a Csk target ameliorated hypertension in Csk+/- heterozygote mice, suggesting that Csk regulates blood pressure through Src.There has been no functional study to support the link of these genes to blood pressure. Based on eQTL analysis studies, mouse homologs All mice were housed and handled in a pathogen-free facility of College of Pharmacy at Kyung Hee University in compliance with the Guide for the Care and Use of Laboratory Animals, fully accredited by the Association for Assessment and Accreditation of Laboratory Animal Care. The mice were maintained on a 12-hour light/dark cycle at a constant temperature with free access to food  and water. Every effort was made to minimize the number of sacrificed animals and their suffering. Animals were anesthetized by intraperitoneal (i.p.) injection of tribromoethanol (18 ml of the working solution per kg body weight), of which the working solution was diluted 40-fold in 0.9% NaCl from the stock solution  and euthanized by removing the heart. The experiment was approved by the local committee for the Care and Use of Laboratory Animals, College of Pharmacy Institutional Animal Care and Use Committee (license number: KHP-2010-04-06).Csk knockout heterozygote mice, B6.129S-Csktm1Sor/J, were purchased from The Jackson Laboratory . Heterozygote and wild-type homozygote pairs were mated, and the progeny was genotyped by PCR with the primer set using the wild-type (5’-CGCAGTCTACGAGGTGATGA-3’), the mutant (5’-CCTTCTATCGCCTTCTTGACG-3’) and the common reverse primer (5’-GGGCTCAGTTCAAGTTCAGG-3’).Female BALB/c mice  were used at age 7–9 weeks for experiment. in vivo delivery of siRNA have been previously described [Csk, Ulk3, and Cyp1a2) were synthesized by Genolution , and only one of them was selected for in vivo injection. To determine their silencing efficacy, 20 nM of the siRNAs was transfected into B16F10 cells and NIH3T3 cells using G-Fectin  and Lipofectamine 2000  respectively according to their manufacturer’s instructions. TRP53 siRNA was used as a positive control for all in vitro transfection experiments. The target siRNAs and scrambled control siRNA sequences are shown in The selection and escribed –21. In bin vivo delivery into mice, polyethylenimine called as in vivo-jetPEI™  was used as the transfection reagent. According to the manufacturer’s instruction, 50 μg of siRNA and 6.5 μl of in vivo-jetPEI (N/P charge ratio of 6) were diluted with 50 μl of 10% glucose solution and 50 μl of sterile H2O. The solution was vortexed gently and left for 15 min at room temperature. The mixture was injected into the tail veins of 7–9-week-old, female BALB/c mice, and 24 hours after the last injection, the treated mice were used for experiments . The 1-, 2- or 3-time injection means once per day for 1, 2, or 3 days.For the Total RNA was extracted from the tissues of siRNA-injected mice 24 hours after the last injection using TRIzol . cDNA was synthesized from 500 ng of total RNA using the PrimeScript™ RT kit  according to the manufacturer’s protocol. Quantitative real-time PCR analysis was performed using SYBR Green I  on the ABI Step One Real-Time PCR system  using the following program: 45 cycles at 95°C for 10 s, 60°C for 15 s, and 72°C for 20 s. The primer sequences are shown in Csk+/-) over “control” , the 2-∆∆Ct method was used as previously described [Gapdh Ct value was subtracted from each target gene Ct value to obtain the delta Ct (∆Ct) value for normalization and the ∆Ct of the “control” sample was averaged. Second, the averaged ∆Ct value of the “control” sample was subtracted from each ∆Ct value of the “case” sample to obtain the delta delta Ct (∆∆Ct = ∆Ct case—∆Ct control). Third, the ∆∆Ct values are converted to the linear form using the term 2-∆∆Ct. The Standard Error of the Mean (SEM) is calculated from the final 2-∆∆Ct values. Statistical significance was calculated for differences between the 2-∆Ct values of the “control” and those of the “case” samples.To present the data as the fold-change of relative expression of “case”  line (CRL-1999) was purchased from ATCC . This line of VSMC is a normal human cell line established from the normal aorta of an 11-month old child and one of the best-characterized cellular models for the analysis of vascular smooth muscle cell biology. Cells were cultured in F-12K Medium  supplemented with 0.05 mg/ml ascorbic acid, 0.01 mg/ml bovine insulin, 0.01 mg/ml human transferrin, 10 ng/ml sodium selenite, 0.03 mg/ml Endothelial Cell Growth Supplement, 10 mM HEPES, 10 mM TES, and 10% fetal bovine serum under a 5% COTotal proteins were extracted from mouse tissues using PRO-PREP protein extraction solution  according to the manufacturer's instruction. Protein concentrations were measured by Bradford assay .Y416 , anti-phospho-SrcY527 , and anti-Src  from Cell Signaling Technology . The blot was incubated with a horseradish peroxidase-conjugated secondary antibody  for 1 hour at room temperature. Protein signals were detected using Luminol Reagent  and exposed to x-ray films .Total proteins (10 to 40 μg) were separated by 8–10% SDS-PAGE and transferred to a nitrocellulose membrane . The membrane was blocked in 5% skim milk for 30 min at room temperature and subsequently incubated with an antibody overnight at 4°C; anti-Actin , and anti-Csk  from Santa Cruz Biotechnology ; anti-phospho-SrcThe protocol for blood pressure measurement has been previously described –21. In bBlood pressure was monitored for 2 hours after injection of the anesthetic and presented as the average value at each minute between 40 and 80 min (a linear graph) and as the average value during 40 minutes from 40 to 80 min (a bar graph) because blood pressure during the presented period was considered enough stable as evidenced by multiple repeated experiments.Csk+/- and Csk+/+ mice 24 hours after i.p. injection of PP2 or PP3 at doses of 2 or 10 μg per kg body weight.To test the effect of PP2  or PP3, a negative control inhibitor , blood pressure was measured in P < 0.05 was considered statistically significant. * P<0.05, ** P<0.01 versus respective controls.Statistical analysis was performed using SPSS (PASW Statistics 22.0), and all data between case and control groups were analyzed by Mann-Whitney U-test since the U-test was in general considered more powerful than the t-test . All datCYP1A2, CSK, and ULK3 on the human 15q24 locus with the comparable gene locations on mouse chromosome 9 in the opposite direction. The lead SNP (rs1378942 designated as *) is located in the first intron of CSK. To test the effect of candidate gene variation on blood pressure, we used silencing of candidate genes by siRNA injection into mice in vivo. Both mouse homologs Csk and Ulk3 were selected as comparably strong candidate genes among nearby genes on the 15q24 locus based on eQTL analysis studies (Cyp1a2 was tested as a negative control because there has been reported neither significant association with blood pressure in GWAS or significant link to the lead SNP (rs1378942) in eQTL resources , in kidney by 20% (P = 0.038), and in lung by 29% (P = 0.017), respectively, and Ulk3 mRNA levels fell in lung by 32% (P = 0.001) (Cyp1a2 mRNA levels fell in liver by 49% (P = 0.036) and in kidney 21% (P = 0.032)  . Cyp1a2 = 0.032) .Csk, Ulk3, or Cyp1a2 (negative control) siRNAs.To study the functional effect of siRNA injection, blood pressure was measured 24 hours after the last injection of Cyp1a2 siRNA-injected group  compared with control groups  (P = 1.000)  showed significantly increased blood pressure compared with control groups  (P<0.001)  did not show significant changes in blood pressure versus control mice  (P = 1.000)  . HoweverP<0.001) . Interes= 1.000) .Csk, Ulk3, and Cyp1a2 mRNA levels were measured in mice tissues after 2-time injection of each siRNA. Csk mRNA levels decreased significantly in heart by 31% (P = 0.001) and in liver by 19% (P = 0.01), respectively, and Ulk3 mRNA levels also decreased in liver by 34% (P = 0.001), in spleen by 37% (P = 0.001), and in lung by 44% (P = 0.003), respectively  after 2-time injection  were knock-downed by siRNA injections in various tissues.To confirm reduction of the target gene mRNA, ectively . Cyp1a2 njection . The resCsk siRNAs were injected into mice once per day for 3 days (3-time injection). Blood pressure significantly differed between Csk siRNA-treated mice  and control mice  (P = 0.017) even after 3-time injection  (To study Csk protein levels in  tissues . After 2= 0.016) . These dCsk siRNA-injected mice, we examined Csk knockout mice. Because the Csk knockout homozygote (Csk-/-) was embryonic-lethal, the Csk heterozygote (Csk+/-) mice were compared with the wild-type (Csk+/+) mice. The Csk mRNA level in Csk heterozygotes decreased in most tissues by half   .Csk+/- and Csk+/+ mice. Csk protein levels were reduced by 52% (P = 0.002) in the Csk+/- aorta  significantly increased by 38% (P = 0.046) and that of SrcY527 (inactive) decreased by 25% (P = 0.01), suggesting Src as a target of Csk in the aorta  was significantly reduced 24 hours after i.p. injection of 10 μg PP2 per kg body weight   while PP2 did not affect the basal blood pressure in the wild-type  , indicating that PP2 was specific in its effect on blood pressure  . Lesser  N = 10) . We studpressure .Csk+/- and Csk+/+ mice treated with 10 μg/kg PP2. As shown in Y416 (active) was significantly reduced in the PP2-treated Csk+/- aorta compared to vehicle-treated aorta and phosphorylated SrcY527 (inactive) was also slightly decreased.To confirm inhibition of Src by PP2, we performed Western blotting analysis for phosphorylated Src proteins in the aorta of Csk siRNA, and then treated with 10, 25, 50 μM PP2 for 24 hours. The Western blotting analysis showed that phosphorylation of SrcY416 was conspicuously increased by Csk siRNAs transfection in VSMCs consistent with the result from the Csk+/- mice aorta , transfected cells with ce aorta . Moreoveed cells . Phosphoin VSMCs .These results suggest that Src is specifically involved in blood pressure regulation by Csk.in vivo delivery of candidate gene siRNA into mice.It has been a challenging task to identify a causative gene in a locus that is associated with blood pressure. Therefore, there are very few genes identified as causative so far despite of multiple candidates associated with blood pressure GWASs. For that reason, we utilized two-step approaches. First, we selected the most relevant candidate genes in a locus by using the eQTL analysis studies. Then, we tested the effect of gene knock-down on blood pressure after the ATP2B1 in the 12q21 locus [ATP2B1 transcripts was associated with rs1401982 and rs17249754  [in vivo siRNA silencing. The SORT1 gene is another good example that a specific gene is identified as associated with a variant (rs599839) in the 1p13 locus by an eQTL study (P = 6.11×10−55 in liver) and that rs629301 in LD with rs599839 is associated with plasma low-density lipoprotein cholesterol (LDL-C) in GWAS (P = 1×10−170) [SORT1 gene and knockdown by Sort1 siRNA in mouse liver changes plasma LDL-C levels [We previously reported 21 locus  as a caun blood) , support×10−170) , 29. MusCSK and ULK3 were selected in the 15q24 locus for further study. Target gene silencing was successfully tested in vivo according to the protocol we have previously established. As a result, Csk in the 15q24 locus was identified as a causative gene for the blood pressure change and furthermore confirmed in a knockout mouse model. Therefore, the present study and previous ones support that in vivo siRNA silencing combined with the eQTL analysis is a very useful tool to identify a causative gene among candidate genes.In the present study we used the eQTL resources more aggressively to sort out prominent candidates. Through mining the eQTL resources, Csk in mice from the results obtained in human GWAS and eQTL studies that the ‘C’ allele of the lead SNP (rs1378942) is associated with higher blood pressure and higher CSK transcripts [CSK and mouse Csk gene. But it is very unlikely since the human CSK and mouse Csk proteins are identical except one residue at 123 within SH2 domain, not within a functional domain such as the kinase domain. The other one is a recording error for SNP alleles in eQTL databases. We personally corresponded with authors of Fehrmann et al. (2011) and Grundberg et al. (2012) papers but were provided with a solid confirmation for their databases. The third reason might be the lack of the functional tissue in eQTL resources. We speculate that the correct eQTL data may be unavailable until the functional tissue of CSK for blood pressure regulation is revealed. Despite of still unsolved conflicts, we believe that our results provide an important clue for how the decreased Csk gene activity is associated with hypertension in Spontaneously Hypertensive Rats (SHR) [However, we observed a difference in the directionality of the effect of suppression of  rs137894 is assocnscripts , 12. We ts (SHR) , as explY527, acting as a negative regulator of Src  in rat VSMCs [2+ mobilization is blunted in Src-/- VSMC and vascular contraction is inhibited by PP2, a Src inhibitor [Src is one member of eight Src family tyrosine kinases  . Among tat VSMCs . Ang II-nhibitor . InteresDownstream of the Csk-Src signal, extracellular signal-regulated kinases (ERK1/2) may play an important role in vasoconstriction. In SHRs, inhibition of ERK signaling by U0126 reduces hypertension, vascular thickening, and smooth muscle myosin light chain kinase expression . MoreoveAng II is a major effector hormone of the renin-angiotensin system and has various effects that are mediated by AT1R to raise blood pressure, including direct vasoconstriction in the vascular smooth muscle, indirect vasoconstriction by noradrenaline release from the sympathetic nerve system, sodium reabsorption in the kidney, sodium and fluid retention by aldosterone secretion from the adrenal gland, and vascular growth stimulation .Src siRNA inhibits Ang II-induced epithelial-to-mesenchymal transition (EMT) associated with progressive kidney damage [via apical Na+/H+ exchanger (NHE) and basolateral Na+-HCO3- cotransporter (NBC) and Csk overexpression inhibits activation of both NHE and NBC [In addition to already mentioned role of Src in VSMCs, Src activation is required for Ang II-mediated functions in the kidney and in the brain. In the renal proximal tubule-like cells, PP2 and y damage . Also Sr and NBC , 38. In  and NBC –42. TherIn the hypothalamus of hypertensive rats induced by two-kidney one-clip (2K1C), Src activation is higher than sham-operated rats and is more increased by Ang II . Two speCsk+/- mice may rather be the combined result of differential effects by chronic Src activation in multiple tissues  than the result of a defect in one particular tissue. Therefore, to fully understand the mechanism of hypertension in Csk+/- mice, changes in Src-associated signaling need to be further studied in each tissue.Considering that Src plays regulatory roles in diverse tissues, hypertension in CSK a causative gene in the blood pressure GWAS locus 15q24 by selecting candidate genes using the eQTL analysis studies, by verifying the functional effect of genes using in vivo siRNA delivery in mice, and by confirming our findings in knockout heterozygote mice. Furthermore, we showed that Csk involves Src by negatively regulating its activity to modulate blood pressure. Our result that Csk regulates blood pressure through Src suggests a novel pathway for the development of hypertension and provides a therapeutic target for the treatment of high blood pressure.In summary, we have identified S1 FigCsk+/- and Csk+/+ mice were i.p. injected with DMSO as control (CON) or PP3 (10 μg per kg body weight), a negative control for PP2, and blood pressure was measured 24 hours after injections.(A and B) (PDF)Click here for additional data file.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S3 Table(PDF)Click here for additional data file.S4 Table(PDF)Click here for additional data file.S5 Table(PDF)Click here for additional data file.


To evaluate the clinical evolution and the association between nutritional statusand severity of asthma in children and adolescents enrolled in Primary HealthCare.A retrospective cohort study of 219 asthmatic patients (3-17 years old) enrolledin Primary Care Services (PCSs) in Embu das Artes (SP), from 2007 to 2011.Secondary data: gender, age, diagnosis of asthma severity, other atopic diseases,family history of atopy, and body mass index. To evaluate the clinical outcome ofasthma, data were collected on number of asthma exacerbations, number of emergencyroom consultations and doses of inhaled corticosteroids at follow-up visits in the6th and 12th months. The statistical analysis included chi-square and Kappaagreement index, with 5% set as the significance level.p=0.409). After 1 year offollow-up, 25.2% of patients showed reduction in exacerbations and emergency roomconsultations, and 16.2% reduced the amount of inhaled corticosteroids.50.5% of patients started wheezing before the age of 2 years, 99.5% had allergicrhinitis and 65.2% had a positive family history of atopy. Regarding severity,intermittent asthma was more frequent (51.6%) and, in relation to nutritionalstatus, 65.8% of patients had normal weight. There was no association betweennutritional status and asthma severity (The monitoring of asthmatic patients in Primary Care Services showed improvementin clinical outcome, with a decreased number of exacerbations, emergency roomconsultations and doses of inhaled corticosteroids. No association betweennutritional status and asthma severity was observed in this study. It is characterized by recurrent respiratory symptoms and itsignificantly impairs the quality of life. In Brazil, epidemiological studies carriedout in recent decades indicate a trend of increasing prevalence of asthma in childrenand adolescents.,,,-Epidemiological studies have suggested an association between obesity and asthma, moreconsistent in adults, revealing that obese asthmatic individuals have a higher frequencyof exacerbation crises, emergency room consultations and need for higher doses ofinhaled corticosteroids, as well as greater difficulty in controlling the disease.In 1988, as part of the activities of the Teaching-Care Integration Program developed byUniversidade Federal de São Paulo in the town of Embu das Artes, in the metropolitanregion of São Paulo, the Care Program for Children with "Wheezing" was implemented inpartnership with the Department of Health. The structure of this program considered asits principle the role of primary care in the management and monitoring of the mostprevalent morbidities. The program's population consists of children and adolescentswith recurrent wheezing, treated by a team of pediatricians, undergraduate medicalstudents and medical residents in Pediatrics. The activities developed by the programinclude medical consultations, educational groups for family members and provision ofmedications for asthma control.Portaria N° 2981 of the Ministryof Health, which provides for the regular provision of medications for asthma controlduring crises and for continuous use by the municipality.Ventura et al.-Considering the nutritional transition in Brazil, with the reduction in the prevalenceof malnutrition and increase in the prevalence of obesity,This retrospective cohort involved children aged 3-17 years, enrolled in the CareProgram for Children with "Wheezing" from 1 January 2007 to 31 December 2011, in twoPCSs in the municipality of Embu das Artes. Secondary data obtained from the firstconsultation were collected from patients’ records: age, gender, age at first wheezingcrisis and other atopic diseases , previous hospitalizations forrespiratory diseases, birth weight, family history of atopy , and diagnosis of asthma severity using the clinical criteria of the IVBrazilian Guidelines for Asthma Management, 2006 .2) z-score based on the WHO curves of 2006and 2007, using the Anthro and Anthro Plus programs,,z-score: ≥−3to <−2: thinness; ≥−2 to <+1: normal weight; ≥+1 to <+2: risk of overweight(<5 years) and overweight (≥5 years); ≥+2 to <+3: overweight (<5 years) andobesity (≥5 years); ≥+3: obesity (<5 years) and severe obesity (≥5 years).,Anthropometric data, such as weight (kg), height (cm) and the calculation of body massindex (BMI)  abandoned treatment. Four patients (1.8%)with intermittent asthma were discharged from the program during this period; onepatient with intermittent asthma moved to another city. During this period, 88 patients(40%) missed at least one consultation and thus, 131 patients came to all proposedconsultations, having the complete data to be used in the analysis of the clinicalcourse of the disease.κ=0) and perfect agreement with Kappa index =1. The standard errorof the Kappa index of 5% allowed the estimation of the statistical significance and the95% confidence interval.For the statistical analyses, chi-square tests were used to compare categoricalvariables, with the level of significance being set at 5% and two-tailed statisticaltests. The Kappa index was used to assess the number of crises, emergency roomconsultations and doses of medications used between the first and second semester of theprogram follow-up, with lack of agreement being considered when the value was zero, and z-score of 0.48 ± 5.20 (−2.72 to 5.20).The 219 patients who attended the 1st consultation had a mean age of 6.65 years ±4.89 SD(3-17 years), with most being male (58.4%); 9.3% had low birth weight and 50.5% ofpatients started wheezing before 2 years of age; 91.7% had other atopic conditions,almost all of them with allergic rhinitis (99.5%), and 46% reported previoushospitalization at the start of follow-up. Family history of atopy was positive in 65.2%of patients. As for disease severity, intermittent asthma was the most frequent type(51.6%), and in relation to nutritional status, normal weight predominated (65.8%) amongpatients. The calculated BMI had a mean ± SD of 17.22 ± 3.34 (11.98-36.22kg/mp=0.409).Patient distribution according to the nutritional status and the severity of asthma inthe 1st consultation is described in κ=0.060 andp=0.375); however, 25.2% of the patients improved exacerbations, and19.1% started having more crises in the 2nd semester , butwith a value of κ=0.180, i.e., a poor agreement. When analyzing all theanswers, 57.3% of patients had the same number of emergency room consultations in bothmoments; 25.2% showed improvement and 17.6% showed worsening of the clinical picture,with more emergency room consultations, with this fact explaining the lack of agreementbetween the results.p=0.001), with a value of κ=0.569, indicatingmoderate agreement. It can be observed that 73.8% of patients remained with the samedose of corticosteroids in the 1st and 2nd semesters, indicating a high correlationbetween the results in the two moments; 10.0% of patients showed worsening and it wasnecessary to start using inhaled corticosteroids in the 2nd semester, with 2.3% usingmedium and 4.6%, high doses. Of the 16.2% of patients who improved, 8.4% reduced theamount and 7.7% stopped using medication in the 2nd semester of follow-up. A patientusing the association of inhaled corticosteroids/long-acting bronchodilator in the 2ndsemester was excluded from this table to allow statistical analysis. Additionally, itwas observed that 11.3% of patients in the 1st semester showed irregular use of inhaledcorticosteroids, and 8% in the 2nd semester of follow-up.p=0.057).-,Given the increasing prevalence of asthma,When analyzing the nutritional status of asthmatic patients in this study, it isobserved that the results contrast with the findings of Ventura et al.In this study, when assessing the nutritional status and asthma severity in 1stconsultation, the severe form of the disease was observed only in patients with excessweight, while Ventura et al. observed the highest prevalence of malnutrition in themoderate/severe asthma group in the 1988-1993 period in the same municipality, despitethe differences in nutritional classification criteria used at the time.Regarding the clinical diagnosis of disease severity in the 1st consultation, thehighest frequency was of intermittent asthma (51.5%), while severe asthma was observedin only 1.4%, a similar rate to that reported in the IV Brazilian Guidelines for AsthmaManagement, 2006.In the present study, we assessed the influence of high BMI and asthma severity, as wellas disease control after a year of follow-up of patients enrolled in the program. Theanalyses showed no associations between nutritional status and asthma severity, as wellas between nutritional status and disease control.,Studies on the association between asthma and obesity show heterogeneous results due tothe use of different methods for asthma severity classification, with some reportingsymptoms of wheezing, while others use medical diagnosis or objective measurements suchas spirometry, therefore showing varied results. Farah and Salome,,Regarding asthma control, the association between obesity and worse disease control isnot well established yet. Quinto et al.The present study assessed the evolution of asthma considering patients who attended allproposed consultations, considering that the characteristics of these patients may bedifferent from those who left the program and the ones who missed the consultations,which may have limited the analyses of disease evolution. The quantification of thenumber of crises may have been influenced by recall bias, especially when exacerbationsoccurred several times during one semester; the emergency room consultations areimportant events in a patient's life, making records more reliable. On the other hand,patients started the Program follow-up in different months of the year, thus reducingthe bias of asthma exacerbations due to seasonality.During 1 year of follow-up, 25.2% of patients reduced the number of crises and emergencyroom consultations. Of the patients who showed worsening, only 19.1% had more crises,and 17.6% required more emergency room consultations in that period. It was observedthat the proportion of asthmatics who showed improvement was higher than the ones whoshowed worsening, demonstrating the benefits of monitoring in those patients who joinedthe program.Ventura et al.Portaria N° 2981 of the Ministry of Health.According to this study, most patients showed treatment adherence. An important part ofthese results should be attributed to the provision of asthma medications by the PublicHealth System PCSs, including the municipality of Embu das Artes, since 2009, with theImproved adherence to the program by patients and family members was demonstrated by thedecrease in the abandonment rate, from 53.2%However, despite the consistent improvement in program adherence and follow-up, thisstudy has some limitations, such as obtaining some secondary data , andthe loss of information on patients that missed appointments or abandoned the program,while study data was being collected. In spite of these limitations, we can concludethat the study showed no associations between nutritional status and asthma severity andcontrol. Adherence to treatment resulted in a decreased number of asthma crises,emergency room consultations during the follow-up period, in addition to decreasing thedoses of inhaled corticosteroids. This study emphasizes the importance and feasibilityof asthmatic patients follow-up in PCSs. Moreover, the implementation of public policiesthat facilitated the introduction of specific medications for asthma treatment, the mostcommon chronic disease in childhood, in Primary Health Care contributed to the favorableoutcome of this evolution. -diabetes melittus e síndrome metabólica, além de exacerbar aasma.-A asma é uma doença inflamatória complexa, reconhecida como uma das doenças crônicasmais comuns da infância. Caracteriza-se por manifestações respiratórias recorrentes ecompromete de forma significativa a qualidade de vida. No Brasil, estudosepidemiológicos feitos nas últimas décadas apontam para uma tendência de incrementoda prevalência de asma em crianças e adolescentes.,,,-Estudos epidemiológicos sugerem uma associação entre a obesidade e a asma, maisconsistente em adultos, e observam que os obesos asmáticos apresentam maiorfrequência de crises de exacerbações, atendimentos nas urgências e necessidade demaiores doses de corticoides inalatórios, além de maior dificuldade no controle dadoença.Em 1988, como parte das atividades do Programa de Integração Docente-Assistencialdesenvolvido pela Universidade Federal de São Paulo (Unifesp) no município Embu dasArtes, na Região Metropolitana de São Paulo, foi implantado, em parceria com aSecretaria Municipal de Saúde, o Programa de Atenção às Crianças Portadoras de"Chiado no Peito". A estruturação desse programa considerou como princípio o papel daatenção básica na assistência e no acompanhamento das morbidades mais prevalentes. Apopulação do Programa é constituída por crianças e adolescentes com sibilânciasrecorrentes, que são assistidas por uma equipe composta por pediatras, alunos dagraduação do curso de medicina e médicos residentes de pediatria. As atividadesdesenvolvidas pelo Programa incluem consultas médicas, grupos educativos para osfamiliares e fornecimento das medicações para o controle da asma.Ventura et al.-Considerando a transição nutricional no Brasil, com redução da prevalência dadesnutrição e o aumento da obesidade,O presente estudo, de coorte retrospectiva, envolveu o universo de crianças maioresde três anos até adolescentes de 17 anos, matriculados no Programa de Atenção àsCrianças Portadoras de "Chiado no Peito", de 1 de janeiro de 2007 a 31 de dezembro de2011, em duas UBS, no município de Embu das Artes. Dos prontuários dos pacientesforam coletados dados secundários da primeira consulta: idade, sexo, idade naprimeira crise de sibilância e outras doenças atópicas ,internações prévias por doenças respiratórias, peso ao nascer, antecedente familiarde atopia  e diagnóstico da gravidade da asma com o uso doscritérios clínicos da IV Diretrizes Brasileiras para o Manejo da Asma, 2006 .2) em escore z segundo as curvas de OMS 2006 e2007, com o uso dos programas Anthro e Anthro Plus,,,Os dados de antropometria, como o peso (kg), a estatura (cm) e o cálculo de Índice deMassa Corporal (IMC)  abandonaram o tratamento. Quatro com asma intermitente receberam alta do Programa nesse período; um pacientecom asma intermitente mudou para outro município. Durante esse período, 88 pacientes(40%) faltaram pelo menos a uma consulta e, assim, 131 compareceram a todas asconsultas propostas e apresentaram os dados completos para analisar a evoluçãoclínica da doença.Para as análises estatísticas foram usados testes de qui-quadrado para comparar asvariáveis categóricas, o nível de significância foi de 5% e o teste estatísticobicaudal. O índice de concordância Kappa foi usado para avaliar os números de crises,atendimentos de urgência e as doses de medicamentos usadas entre o primeiro e segundosemestre de acompanhamento no Programa. Foi considerada não concordância quando ovalor calculado foi igual a zero (κ=0) e concordância perfeita com índice de Kappaigual um. O erro padrão do índice de Kappa de 5% permitiu estimar a significânciaestatística e o intervalo de confiança de 95%.Este estudo foi aprovado pelo Comitê de Ética da Secretaria Municipal de Saúde deEmbu das Artes e também aprovado pelo Comitê de Ética em Pesquisa da Unifesp, n°1.821/11.2) e escore z de 0,48±5,20 .Os 219 pacientes que compareceram à primeira consulta apresentaram média de 6,65 anos±4,89 DP (3-17 anos); a maioria era do sexo masculino ; 9,3% nasceram combaixo peso e 50,5% iniciaram a sibilância antes dos dois anos; 91,7% apresentaramoutras atopias, quase todos com rinite alérgica , e 46% relataram internaçãoprévia ao início do acompanhamento. A história familiar para atopia foi positiva em65,2% dos pacientes. Quanto à gravidade da doença, a asma intermitente foi maisfrequente  e em relação à condição nutricional houve predominância de eutrofia. Entre os pacientes o IMC calculado teve média ± DP de 17,22±3,34.A distribuição dos pacientes segundo o estado nutricional e a gravidade da asma naprimeira consulta está descrita na p=0,375), porém 25,2% dos pacientes melhoraram as exacerbações e19,1% passaram a ter mais crises no segundo semestre , porém com um valor de κ=0,180; umaconcordância pobre. Ao analisar todas as respostas, 57,3% dos pacientes tiveramnúmero de idas aos serviços de urgência igual nos dois momentos; 25,2% apresentarammelhoria e 17,6% pioraram o quadro, com mais atendimentos nas urgências. Essa é aexplicação para a não concordância entre os resultados.A p=0,001), com um valor de κ=0,569, o que aponta concordânciamoderada. Nota-se que 73,8% dos pacientes permaneceram com a mesma dose de corticoideno primeiro e no segundo semestre, o que aponta alta concordância entre os resultadosnos dois momentos; 10% dos pacientes pioraram e houve a necessidade de iniciar uso docorticoide inalatório no segundo semestre; 2,3% usaram dose média e 4,6% dose alta.Dos 16,2% pacientes que melhoraram, 8,4% reduziram a quantidade e 7,7% pararam deusar medicação no segundo semestre de acompanhamento. Um paciente que usou associaçãocorticoide inalatório/broncodilatador de longa duração no segundo semestre foiexcluído dessa tabela para possibilitar a análise estatística. Além disso, foiobservado que 11,3% dos pacientes no primeiro semestre apresentaram uso irregular decorticoide inalatório e 8% no segundo semestre de seguimento.A p=0,057).A -,Diante da crescente prevalência de asma,Ao analisar a condição nutricional dos pacientes asmáticos deste estudo, nota-se queos resultados contrastam com os achados de Ventura et al.No presente estudo, ao avaliar o estado nutricional e a gravidade da asma na primeiraconsulta, observou-se a forma grave apenas em pacientes com excesso de peso, enquantoVentura et al. observaram a prevalência mais elevada de desnutrição no conjunto asmamoderada/grave, de 1988 a 1993 no mesmo município, apesar da diferença dos critériosde classificação nutricional adotada na época.Em relação ao diagnóstico clínico de gravidade da doença na primeira consulta, amaior frequência foi de asma intermitente  e grave em apenas 1,4%, o quedemonstra uma proporção semelhante à citada na IV Diretrizes Brasileiras para oManejo da Asma, 2006.No presente estudo, foi avaliada a influência do IMC elevado e a gravidade da asma e,também, o controle da doença após um ano de acompanhamento dos pacientes no Programa.Feitas as análises, não foram demonstradas associações entre o estado nutricional e agravidade da asma e entre o estado nutricional e o controle da doença.,Existe uma heterogeneidade nos estudos sobre a associação asma e obesidade devido aouso de métodos diferentes para classificar a gravidade da asma, alguns usam sintomasreferidos de sibilância, outros usam diagnóstico médico ou mensuração objetiva comoespirometria e, portanto, demonstram resultados variados. Os autores Farah, Salome,em artigo de revisão, apontaram as controvérsias da associação obesidade e piorgravidade da asma.,Em relação ao controle da asma, ainda não está bem estabelecida a associação entre aobesidade e pior controle da doença. Os autores Quinto et al. observaram que ascrianças e adolescentes com sobrepeso e obesidade apresentaram pior controle da asmacom mais exacerbações e maior uso de medicações de resgate.O presente estudo avaliou a evolução da asma considerando os pacientes quecompareceram a todas as consultas propostas, tendo em vista que as característicasdesses pacientes possam ser diferentes daqueles que abandonaram o Programa e dos quefaltaram às consultas, o que pode ter limitado as análises da evolução da doença. Aquantificação dos números de crises pode ter sido influenciada pelo viés de memória,principalmente quando as exacerbações ocorreram várias vezes no período de umsemestre; os atendimentos nas urgências constituem fatos marcantes na vida dopaciente e tornam os registros mais fidedignos. Por outro lado, os pacientesiniciaram o seguimento no Programa em meses diferentes do ano, o que diminuiu o viésdas exacerbações da asma pela sazonalidade.Em um ano de acompanhamento 25,2% dos pacientes reduziram as crises e as procuras deatendimentos de urgência. Dos pacientes que apresentaram piora somente 19,1% tiverammais crises e 17,6% necessitaram de mais atendimentos de urgências no período.Observou-se que a proporção de asmáticos que melhoraram foi maior dos que pioraram, oque aponta para o benefício do acompanhamento naqueles pacientes que aderiram aoPrograma.Ventura et al. verificaram que os asmáticos moderados e graves reduziram o número decrises ao analisar o período antes e após um ano de acompanhamento, nas mesmas UBS,de 1988 a 1993.De acordo com o presente estudo, a maioria dos pacientes apresentou adesão aotratamento. Uma parcela importante desses resultados deve ser creditada aofornecimento de medicamentos para asma pelas unidades de saúde de rede pública,incluindo o Município de Embu das Artes, desde 2009, com a Portaria n° 2.981 doMinistério da Saúde.A melhoria da adesão dos pacientes e familiares ao Programa foi demonstrada pelaredução da taxa de abandono de 53,2%No entanto, apesar da consistente melhoria na adesão ao Programa e no acompanhamento,este estudo apresenta algumas limitações, como a obtenção de alguns dados secundários(prontuário), além da perda de informações sobre pacientes que faltaram ouabandonaram o Programa durante a coleta de dados do estudo. Apesar de taislimitações, pode-se concluir que não houve, no presente estudo, associações entre oestado nutricional, a gravidade e o controle da asma. A adesão ao tratamentopossibilitou uma redução no número de crises de asma e nos atendimentos de urgênciadurante o período de acompanhamento, além da diminuição nas doses de corticoideinalatório. Este estudo ressalta a importância e a viabilidade do acompanhamento dospacientes asmáticos em UBS. Além disso, a adoção de políticas públicas quefacilitaram a introdução de medicamentos específicos para o tratamento da asma,doença crônica mais frequente durante a infância, na atenção básica em saúdecontribui para os desfechos favoráveis dessa evolução.


It has been proposed that sildenafil citrate can increase ocular blood flow, and that this property can be used to treat ocular disorders that involve reflex vasoconstriction. This study therefore proposes to ascertain the vasodilator effect of the drug on retrobulbar circulation in healthy rabbits. For this matter rabbits treated with sildenafil citrate or saline solution had their intraocular pressure (IOP), mean arterial pressure (MAP), ocular perfusion pressure (OPP) and color Doppler imaging of the external ophthalmic artery measured prior to treatment and on days one (moment M1), seven (when M2), fourteen (moment M3), twenty-one (moment M4), and thirty (moment M5) of treatment.p = 0.0356) and M5 . The IOP and color Doppler values of the external ophthalmic artery did not differ between tested groups.The MAP and OPP values of treated group were lower than those of control group at all times, and the mean values differed statistically at moments M1 (S = 71.52 mmHg, C = 84.76 mmHg, The dose of 10 mg of sildenafil citrate administered to healthy rabbits causes systemic vasodilation and consequently lower values of MAP and OPP. However, it does not induce changes in IOP and retrobulbar hemodynamics identifiable by color Doppler assessment of the external ophthalmic artery. Sildenafil citrate was the first phosphodiesterase type 5 (PDE-5) inhibitor to be approved for treatment of erectile dysfunction, and has become one of the world’s most widely prescribed drugs. This drug inhibits PDE5, enzyme that hydrolyzes cyclic guanosine monophosphate (cGMP), regulating the circulating levels of cGMP, which in turn causes the corpus cavernosum muscles to relax and local blood flow to increase , 2.PDE5, however, is present not only in the corpus cavernosum penis but also in the cells of the smooth muscle of peripheral arteries and veins, and in the pulmonary and coronary circulation, platelets and endothelial cells of blood vessels . TherefoAlthough the drug is widely used for treatment of erectile dysfunction, some users exhibited ocular side effects such as blurred vision and increased sensitivity to light. These symptoms are associated with cross-inhibition of the drug with phosphodiesterase type 6 that is present in the retina, which participates in the regulation of the phototransduction mechanism. However, no consensus has yet been reached about the effects of sildenafil citrate on retinal and retrobulbar blood flow upon inhibiting the PDE5 contained in the walls of the vessels in these regions .According to Silva et al. , identifConsidering the potential of sildenafil citrate for treatment of ocular conditions with reflex vasoconstriction, the purpose of this study was to determine whether the drug has a vasodilator effect on retrobulbar circulation in healthy rabbits, based on an assessment of ocular perfusion pressure and on color Doppler imaging of the external ophthalmic artery.The experiment was based on the recommendations of the Association for Research in Vision and Ophthalmology (ARVO) and Animal Research: Reporting of in Vivo Experiment (ARRIVE) guidelines. The study was also submitted under Proposal No. 027/12, and was approved by the Ethics Committee on Animal Use of the Federal University of Goiás (UFG).The study involved 14 healthy adult male New Zealand white rabbits weighing on average 2.5 kg. The sample size was based on the number required to obtain reliable statistical results. The animals were acquired from a local supplier (MH Cunicultura Coelho Forte), located at Rodovia Bela Vista-Hidrolândia Km 9, Bela Vista de Goiás, Goiás – Brazil. The animals’ eyes and overall health were considered normal after a clinical examination done by an experienced veterinarian, as recommended by TALIERI et al. [n = 7), a control group (C) and a treatment group (S). Group (C) was given 1.5 mL of saline orally, while group (S) was given 10 mg of sildenafil citrate  orally. Both groups were treated at 24-h intervals for 30 consecutive days.The rabbits were divided into two groups of seven animals each  oral administration of the vasodilator sildenafil, (2) measurement of intraocular pressure (IOP), (3) measurement of mean arterial pressure (MAP), and (4) color Doppler imaging of the external ophthalmic artery. Because sildenafil citrate was administered orally, a 45 to 60 min wait time was allowed between ingestion of the drug and the subsequent steps of the protocol.The evaluations were performed weekly, as follows: Day one - moment 1 (M1), Day seven - moment 2 (M2), Day fourteen - moment 3 (M3), Day twenty-one - moment 4 (M4), and day thirty - moment 5 (M5).To measure the IOP and MAP and for the Doppler study, the unsedated rabbits were wrapped in a towel, leaving only the head exposed for the investigator to take the measurements. Care was taken not to apply excessive force in restraining the animals during these evaluations.All the evaluations were performed in triplicate by the same investigator, in a blind study. To reduce the period of restraint, only the right eye of each animal was examined, thus avoiding the effects of stress on the retrobulbar circulation and optimizing the action time of the drug.The intraocular pressure of rabbits was measured with a Tono-Pen AVIA VET® applanation tonometer . The procedure consisted in gently lifting the eyelid, applying a drop of 0.5 % proparacaine  on the eye, and taking a reading with the tonometer five minutes later.TM, Becton Dickinson Indústrias Cirúrgicas Ltda, Juiz de Fora, MG, Brazil). The catheter was then plugged to a semi-rigid silicone tubing system. In this system, two silicone tubes were connected to a three-way stopcock. The free end of one the tube was attached a catheter and the other end to a BD sphygmomanometer . The system was then filled with 1 mL/1000 mL of 0.9 % heparinized saline . The air/liquid interface was positioned at the height of the right atrium and eye, and the mean arterial pressure was read with the sphygmomanometer [After the trichotomy and antisepsis of the dorsal surface of the rabbits’ ears, the central artery was cannulated with a 24G catheter (BD Angiocathanometer .The ocular perfusion pressure (OPP) was determined by subtracting the mean arterial pressure (MAP) from the intraocular pressure (IOP), as described by KIEL & HEUVEN .The color Doppler evaluation of the external ophthalmic artery was performed using a MyLab™ 30 VET ultrasound system  coupled to a 13–18 MHz linear transducer.Before the examination, the cornea was anesthetized by applying one drop of 0.5 % proparacaine hydrochloride topical ophthalmic anesthetic . A layer of sterile aqueous gel was then applied to the corneal surface, and the transducer was gently placed in a longitudinal position, with the position indicator facing the upper eyelid.The sagittal image of the eyeball and optic nerve were recorded in two-dimensional mode. The external ophthalmic artery was identified near the entrance of the optic nerve by color Doppler imaging. The cursor of the pulsed wave Doppler was then immediately positioned over the ophthalmic artery, within the vessel lumen, using the uniform insonation method, to record its blood flow curve, after which the peak systolic velocity (PSV) and end diastolic velocity (EDV) were evaluated based on this curve. The angle was not corrected and measurements greater than 60° were not included. The ophthalmic artery resistance index (RI) was calculated, automatically by the software Mylab desk, witch in based on the Pourcelot equation (RI = PSV − EVS/ PSV), and the curves were analyzed by the same operator (APAC), whom marked the PSV and the EDV of three consecutive curves .A randomized 2 x 5 split-plot experimental design was used, with the treatments corresponding to the plots (with and without sildenafil citrate), the evaluation periods to the subplots (M1 - M2 - M3 - M4 - M5), and each animal to an experimental unit.Using R® statistical software, the data were tested for normality by the Shapiro-Wilk test and subjected to an analysis of variance. The means were compared by the Tukey test, adopting a 5 % level of significance.The mean baseline IOP, MAP and OPP values were 11.85 mmHg, 80.71 mmHg and 68.85 mmHg, respectively, in both groups.p = 0.0356) and M5 . However, the IOP values did not differ statistically during the experimental period  were lower and statistically different from those of group (C) at moments M1 (S = 71.52 mmHg, C = 84.76 mmHg, Prior to treatment, the mean baseline values observed in color Doppler study of the external ophthalmic artery of the right eye of rabbits in both groups were 22.99 cm/s at PSV and 12.29 cm/s at EDV and the resistance index was 0.53. The external ophthalmic artery showed a red flow in the color Doppler and exhibited a laminar flow pattern with intermediate resistivity, dichroism, and the presence of two peak systolic velocities (Fig. In this study, it was found that sildenafil citrate reduced mean arterial pressure in rabbits. In humans, this drug has also been found to cause a significant reduction in systolic and diastolic blood pressure one hour after ingestion , 9. HoweAs for intraocular pressure, no statistical differences were found between the groups. Like this study, other studies on rabbits have shown no significant increases in IOP with the use of sildenafil citrate –16. HoweIn this study, the ocular perfusion pressure of rabbits was calculated based on measured MAP and IOP values. The perfusion pressure of an organ can be defined as the difference between its arterial and venous blood pressure . In rabbThe ophthalmic artery resistance index of rabbits did not change in response to sildenafil citrate. Moreover, it has been shown that the drug does not alter the resistance of the ophthalmic artery in humans . AnotherAlthough the decrease in MAP was expected to lower the external ophthalmic artery resistance index, this was not observed in this study. It is believed that this result may be due to compensatory mechanisms of self-regulation that act on the external ophthalmic artery to maintain the ocular infusion , or thatIn summary, based on the data obtained in this study, it can be stated that a dose of 10 mg of sildenafil citrate administered to healthy rabbits causes systemic vasodilation, lowering their mean arterial pressure and ocular perfusion pressure. However, the drug does not induce changes in the retrobulbar hemodynamics detectable by color Doppler imaging of the external ophthalmic artery, nor does it alter the IOP.ARVO, Association for Research in Vision and Ophthalmology; cGMP, cyclic guanosine monophosphate; EDV, end diastolic velocity; IOP, intraocular pressure; MAP, mean arterial pressure; OPP, ocular perfusion pressure; PDE-5, phosphodiesterase type 5; PSV, peak systolic velocity; RI, resistance index


Sleep-disordered breathing (SDB) is associated with adverse outcomes in patients with chronic heart failure (CHF). Additionally, heart rate turbulence (HRT) reflects changes in the sinus cycle length of baroreceptor in response to hemodynamic fluctuations after ventricular premature beat. Recent studies have suggested that HRT as a marker of vagal activity has a predictive value of poor prognosis in CHF patients. However, little is known about the relationship between SDB and HRT in CHF patients.In this study, 75 patients with CHF were enrolled. We simultaneously performed Holter ECG during a 24-hr period and portable sleep monitoring at nighttime, and determined the respiratory disturbance index (RDI), HRT (turbulence onset (TO) and turbulence slope (TS)) during that 24-hr period. These patients were divided into two groups based on the presence of severe SDB: Group A  and Group B . TS was significantly lower in Group A than in Group B across the 24-hr period . TO did not differ between the two groups. Furthermore, there was a significant negative correlation between all-day TS and RDI . Moreover, in the multiple regression analysis, RDI was an independent factor to determine all-day TS.In patients with severe SDB, blunted TS was observed across 24 hours. These results suggest that SDB induce impairment of vagal activity across a 24-hour period and may be associated with poor prognosis in CHF patients. Despite recent advances in its medical management, chronic heart failure (CHF) still leads to high mortality and morbidity. CHF is characterized by an autonomic imbalance with impaired vagal activity and increased sympathetic activity About 50% of CHF patients have sleep-disordered breathing (SDB), which consists of obstructive sleep apnea (OSA) and Cheyne-Stokes respiration with central sleep apnea (CSR-CSA). SDB, especially severe SDB, is associated with cardiovascular mortality This study enrolled 112 consecutive patients with CHF who were referred for an overnight test with a portable sleep monitor and a 24-hr Holter ECG test, regardless of SDB symptoms, at Fukushima Medical University. Inclusion criteria were (1) the presence of symptomatic CHF in New York Heart Association class II–III We performed simultaneous overnight portable sleep monitoring and 24-hr Holter ECG monitoring. Standard Holter ECG recorders  were used to acquire data. Two independent physicians, each one blinded to the results of the other, analyzed polygraphy and Holter ECG. Written informed consent was obtained from all study subjects. The study protocol was approved by the Ethical Committee of Fukushima Medical University.2) by pulse oximetry as previously reported 2>3% 2), and mean pulse oxygen saturation (mean SpO2) All subjects underwent overnight polygraphy with the use of standard techniques All patients underwent 24-hr Holter ECG and we obtained their HRT and heart rate variability (HRV) parameters as previously reported 2In time domain analysis, standard deviation of all NN intervals (SDNN), standard deviation of the averages of the entire recording (SDANN), the square root of the mean of the sum of the squares of differences between adjacent NN intervals (RMSSD), the number of pairs of adjacent NN intervals differing by more than 50 ms in the entire recording (NN50), and the NN50 count divided by the total number of all NN intervals (pNN50) were measured across a 24-hour period Blood samples were obtained the morning after the polygraphy, while the patient was in the supine position in the fasting state. Plasma BNP level was measured using a specific immunoradiometric assay . Estimated glomerular filtration rate (eGFR) was measured by the Modification of Diet in Renal Disease formula t-test for normally distributed data and the Mann-Whitney U test for non-normally distributed data for continuous variables, and the chi-square test was used for categorical variables. Correlations between RDI and TS were assessed using Spearman correlation analysis. Multivariable regression analysis was used to determine factors related to all-day TS. To prepare for potential confounding, we introduced the following factors, known to affect the TS into models: age, gender, NYHA functional class, heart rate , ischemic etiology, β-blockers therapy, eGFR, LVEF, and RDI. Parameters with statistical significance in the univariable analysis (P<0.10) were included in the multivariable analysis. A value of P<0.05 was considered significant for all comparisons. Finally, A value of P<0.05 was considered significant. These analyses were performed using a statistical software package .Normally distributed data are presented as mean ± SD, and non-normally distributed data are presented as median (inter-quartile range). Categorical variables are expressed as frequencies and relative frequencies. HRT and HRV data are presented as mean ± SE. Characteristics between the two groups were compared using the independent Student’s 2 and mean SPO2 were significantly lower in Group A than in Group B.There were 17 patients with severe SDB (Group A RDI≥30/h) and 58 patients with none to moderate SDB . Comparisons of clinical characteristics between Group A and Group B are shown in 2, P = 0.011) were significantly lower in Group A than in Group B. In contrast, RMSSD, pNN50, VLF, LF, and HF did not differ between the two groups. Furthermore, as shown in In this study of CHF patients with severe SDB, blunted TS was observed not only at nighttime but also across a 24-hour day. Furthermore, in the multiple regression analysis, RDI was an independent factor to determine all-day TS in CHF patients. This is, to our knowledge, the first study to show that SDB may induce impairment of vagal activity across a 24-hour period in CHF patients.Monitoring heart rate behavior and response is especially important for CHF patients because early autonomic nervous system dysfunction and neurohormonal activation play a dominant role in the progression and prognosis of this disease. SDB  is characterized by recurrent hypoxia, arousal, and the generation of exaggerated negative intrathoracic pressure, which increases sympathetic nervous activity, reduces cardiac parasympathetic activity, and causes repetitive surges in heart rate, blood pressure, and left ventricular preload and afterload, resulting in decreasing stroke volume In the present study, we first demonstrated impairment of TS in CHF patients with severe SDB, and the severity of SDB is an independent factor of impaired vagal activity during the 24-hour period, regardless of age, heart rate, etiology, cardiac function and β-blocker therapy. These data may provide us with novel mechanistic and therapeutic insights to understand the clinical impacts of SDB on CHF patients. Thus, the impaired vagal activity protective approach by treatment of SDB has clinically important implications for improving the prognosis of patients with CHF.Our study has some limitations. First, our study was just observational nature and had no control groups such as patients with only SDB without CHF, and patients without SDB and CHF. Second, the patients with atrial fibrillation were excluded, because HRT could not be determined in the presence of atrial fibrillation. Third, the gold standard for diagnostic testing of SDB is full-channel polysomnography, which provides detailed information about complete differentiation of the types of apnea. Therefore, our differentiation of SDB by portable sleep monitor might have been less reliable than by full polysomnography. Finally, the sample size was relatively small. Large-scale clinical trials may be required to confirm the impact of SDB on HRT in CHF patients.In patients with severe SDB, blunted TS was observed across a 24-hour period. Furthermore, SDB is an independent factor of impaired TS. Common pathological mechanisms underlying SDB and CHF, leading to baroreceptor reflex suppression, may cause abnormal heart rhythm turbulence in CHF patients with severe SDB. These results suggest that SDB induce impairment of vagal activity across a 24-hour period and may be associated with poor prognosis in CHF patients.