Inflammation is a risk factor for both depression and cardiovascular disease. Depressed mood is also a cardiovascular risk factor. To date, research into mechanisms through which inflammation impacts cardiovascular health rarely takes into account central effects on autonomic cardiovascular control, instead emphasizing direct effects of peripheral inflammatory responses on endothelial reactivity and myocardial function. However, brain responses to inflammation engage neural systems for motivational and homeostatic control and are expressed through depressed mood state and changes in autonomic cardiovascular regulation. Here we combined an inflammatory challenge, known to evoke an acute reduction in mood, with neuroimaging to identify the functional brain substrates underlying potentially detrimental changes in autonomic cardiovascular control.18FDG-PET) were analysed to localise central mechanisms of inflammation-induced changes in cardiovascular state: three discrete regions previously implicated in stressor-evoked blood pressure reactivity, the dorsal anterior and posterior cingulate and pons, strongly mediated the relationship between inflammation and blood pressure. Moreover, activity changes within each region predicted the inflammation-induced shift in LF/HF balance. These data are consistent with a centrally-driven component originating within brain areas supporting stressor evoked blood pressure reactivity. Together our findings highlight mechanisms binding psychological and physiological well-being and their perturbation by peripheral inflammation.We first demonstrated that alterations in the balance of low to high frequency (LF/HF) changes in heart rate variability (a measure of baroreflex sensitivity) could account for some of the inflammation-evoked changes in diastolic blood pressure, indicating a central  origin. Accompanying alterations in regional brain metabolism (measured using  PatientThere is increasing biological understanding of the relationship between physical and psychological health. Functional polymorphisms within pro-inflammatory cytokine genes such as Interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha  may increase the risk of depression and are associated with reduced responsiveness to conventional antidepressant therapy . FurtherInflammation is also implicated in the aetiology of cardiovascular disease . Two broCardiovascular research has recognised the increased cardiovascular morbidity observed following acute inflammatory episodes such as respiratory or urinary tract infections  and seveChronic mild inflammation has also been linked in cross-sectional studies to essential hypertension , one of Heart rate variability (HRV) is a non-invasive index of beat-to-beat changes in heart rate. Overall HRV reflects parasympathetic neural activity interacting with sympathetic influences on the sinus node of the heart and reflects the capacity for parasympathetic inhibition of autonomic arousal. HRV decreases under both physical and emotional stress and increases with rest. High HRVindicates a healthy autonomic nervous system that can respond flexibly to dynamically changing environmental demands while low HRV is frequently a marker of ill-health. Low HRV is an independent risk factor for cardiovascular morbidity and mortality  and may Specific brain regions, notably the subgenual cingulate cortex  are impl18Fluorodeoxyglucose (FDG) PET neuroimaging before and 4 h after Typhim or placebo  injection. Specifically we test the hypotheses that (1) direct measures of vascular response to inflammation (blood pressure changes) reflect central adjustments to autonomic control apparent as shifts in LF/HF balance  inf balance  (3) a su balance  will med22.1Twenty healthy male participants (mean 24.7 ± 6.8 years) were recruited from advertisements on a local community website. Nineteen were white-Caucasian and 1 black-African. Volunteers were reviewed by a psychiatrist (N.A.H.) and screened for a history of any relevant physical or psychiatric illness. One participant had a history of mild eczema. Four participants rated their general health as excellent, 9 very good and 7 good. No participant rated his or her general health as poor or fair. All were medication free, with no non-steroidal or steroidal inflammatory drug use in the preceding 2 weeks and were non-smokers. Volunteers who had received typhoid vaccine within 3 years or other vaccine within 6 months were excluded. Participants were advised not to consume caffeinated beverages or alcohol, avoid high-fat meals and refrain from excessive exercise for 24 h prior to testing. All were fasted for a minimum of eight hours prior to testing and consumed only water until completion of the study. After complete description of the study to the participants, written informed consent was obtained. Procedures were approved by the Brighton East National Research Ethics Committee.2.218fluorodeoxyglucose positron emission tomography (18FDG-PET) imaging sessions at baseline then again at 4 h. At the beginning of the study a small calibre venous cannula was inserted into the back of the left hand from which blood samples were taken then 18FDG PET tracer administered prior to each scan. PET scanning was performed for 35 min following a 30-min uptake phase. During and one hour prior to each PET scan participants were instructed to lay still with their eyes open in a dimly-lit room. During scanning heart rate was continuously recorded using a Pulse Oxymeter . Following the first scanning session participants randomly received injections of either 0.025 mg Salmonella-typhi capsular polysaccharide vaccine  or0.5 ml normal saline (placebo) intramuscularly into the deltoid muscle. At the end of the study a high-resolution inversion-recovery echoplanar image was obtained to aid registration of the PET images. Participants also performed memory testing after each PET scan and an additional PET scan 4 h after completion of this study – details of which are not reported here.We adopted a randomized, double-blind, repeated measures design in which all participants underwent g for 10 min at room temperature. Plasma was removed, aliquoted and immediately frozen in liquid nitrogen before transfer to a −80 °C freezer for storage. Plasma interleukin-6 (IL-6), interleukin-1 Receptor antagonist (IL-1Ra) and tumor necrosis factor alpha (TNFα) were assessed using high sensitivity ELISAs . The limit of detection of the IL-6 assay is0.039 pg/mL, with intra- and inter-assay coefficients of variation (CVs) of 7.4% and 7.8%. The IL-1Ra assay had a limit of detection of 6.26 pg/mL and inter- and intra-assay CVs of 5.3% and 8.6% respectively. The TNFα assay had a detection limit of 0.038 pg/mL with intra- and inter-assay CVs of 5.3% and 8.4% respectively. Cytokine analyses were performed using mixed measures ANOVAs in SPSS 16.0.Inflammatory Model: We used a Salmonella-typhi vaccination inflammatory model that has previously been shown to induce a low-grade inflammatory response (indexed by a 2- to 3-fold increase in circulating inflammatory cytokines from 2 h after vaccination) and increase in diastolic blood pressure  without 2.3http://bsamig.uku.fi/, Biosignal Analysis and Medical Imaging Group, Department of Physics, University of Kuopio, Finland) using fast fourier transform (FFT) based on Welch’s periodogram method.Blood pressure was recorded prior to each scanning session using an electronic blood pressure monitor . Blood pressure was recorded twice at each session and the mean pressure recorded. Continuous heart rate was recorded throughout each PET scanning session using a pulse oxymeter . Data were recorded at 500 Hz in Spike 2 version 7 via a Power 1401 Amplifier .Heart rate data were visually inspected, artefact removed and interbeat intervals calculated using custom software in Matlab 2008. Heart rate variability (HRV) within high (0.15–0.4 Hz), low (0.04–0.15 Hz) and very low (0–0.04 Hz) frequency bands were then assessed by calculating the power spectral density (PSD) derived from artefact free 20 min pulse oximetry recording periods. Measures of heart rate variability derived from pulse oximetry has been validated against (less convenient) electrocardiographic methods e.g. . Lowfreqhttp://quantpsy.org/sobel/sobel.htm using the Goodman test equation Z score = a*b/SQRT(b2*sa2 + a2*sb – sa2*sb2) where a is the raw (unstandardized) regression coefficient for the association between the independent variable (inflammation) and the mediator (LF/HF), sa is the standard error of a, b is the raw coefficient for the association between the mediator (LF/HF ratio) and the dependent variable (dBP)  and sb is the standard error of b.All cytokine and physiological data were analysed using mixed measures ANOVA with time as within subject and group as between subject factors in SPSS 19. Regression analyses followed by Goodman test for mediation were used to investigate relationships between inflammatory challenge, change in blood pressure and change in sympathetic/ parasympathetic balance. Mediation analyses were performed using the interactive calculation tool for mediation tests: 2.418FDG tracer administration (mean 155.3 ± 11.8 MBq) on a Siemens Biograph 64 PET-CT scanner in 3D dynamic list acquisition mode. Participants lay supine with their eyes open and mild head restraint was applied. Prior to each PET acquisition a low dose CT scan  was acquired for attenuation correction. After correction for scatter, randoms and effects of attenuation, images were reconstructed in 35 one-minute windows using Siemens proprietary iterative 3D reconstruction schema with 21 iterations and 8 subsets. Individual 1 min scans were then realigned and summed to produce a single 35 min activation scan per session which was co-registered to subjects’ structural MRI scans. Activation images were then normalised using the flow fields acquired from segmentation of corresponding structural MRI scans then spatially smoothed with a 12 mm FWHM Gaussian kernel using standard SPM methods.PET scans were acquired for 35 min starting 30 min after Activation images were included in subject specific paired samples t-tests using a grand mean scaled value of 50 ml/dl/min and proportional scaling to produce subject specific contrast images (4 h > baseline) corrected for overall cerebral glucose metabolism. These contrast maps were then included in a single level whole brain mediation analysis  to inves33.1F = 6.91, p = 0.017)  = 11.77, p = 0.003). Main effects of group and time were non-significant at p < 0.05. As observed previously using the typhoid vaccine inflammatory model  = 2.49, p = n.s.).Cytokine analysis confirmed a significant increase in systemic inflammation following inflammatory challenge demonstrated by significant group × time interactions for both IL-6 (= 0.017)  A and ILry model , TNF-alp3.2F = 5.88, p = 0.026),main effect of time F = 2.65, p = n.s.  = 0.07, p = n.s). LF/HF ratio significantly increased across the duration of the study  = 6.72, p = 0.02) likely associated with the psychological stress of being enrolled in the study with a significantly greater increase following inflammation versus placebo  = 8.06, p = 0.01, F = 4.32, p = 0.05) with a smaller(non-significant) reduction in high frequency (parasympathetic) components observed  = 1.80, p = 0.19).Inflammation but not placebo was associated with a significant increase in diastolic blood pressure (Group × time interaction: p = n.s. B. Systolp = 0.017), Group and change in LF/HF ratio (Pearson = 0.56 p = 0.01), change in LF/HF ratio and BP . Subsequent mediation analysis of these bivariate relationships demonstrated that the relationship between inflammation and change in blood pressure was mediated by central effects on LF/HF ratio , change in diastolic blood pressure and change in LF/HF ratio demonstrated significant correlations between each factor: Group and BP change (Pearson = 0.53 3.3a-priori regions of interest) together with left posterior ACC additionally survived formal mediation analysis  = 39.30, p < 0.0001), group × change in LF/HF ratio interaction  = 7.08, p = 0.006), dorsal ACC main effect of group  = 49.95, p < 0.0001), group × change in LF/HF ratio interaction  = 11.00, p = 0.001), posterior cingulate cortex main effect of group  = 24.29, p < 0.0001), group × change in LF/HF ratio interaction  = 6.50, p = 0.009). This suggests that each region contributes to inflammatory effects on resting blood pressure via a shift in autonomic balance away from cardio protective LF/HF balance.To determine whether these three regions were also sensitive to effects of inflammation on autonomic balance we performed regression analyses (within a GLM with inclusion of a dummy variable to code inflammation/placebo) on each region C, F, H. 4First, we show that acute inflammatory challenge using Typhim vaccination is associated with a significant increase in diastolic blood pressure at four hours. This finding replicates our previous data using this experimental model . We thenOur interpretation is supported by our mediation analysis that showed that the effects of inflammation on resting diastolic blood pressure were mediated via a shift in LF/HF ratio. An increase in baroreflex sensitivity  and dorsal anterior cingulate (dACC), insula, amygdala and pons with the addition of the posterior cingulate cortex (pCC), hasalso been implicated in regulating blood pressure changes to a range of cognitive stressors . Activitreduction in glucose uptake within the pons following inflammation . Indeed, mediation analysis of this alternate causal path remains significant, albeit at a lower statistical threshold, suggesting contributions from both pathways. Dual influences from these ascending and descending pathways may also account for our somewhat surprising finding of a negative correlation between dACC activity and change in blood pressure and LF/HF ratio  of dACC sensitivity to inflammatory status and pons to inflammation-induced changes in mean arterial pressure. Interestingly, in our previous study  though wammation A. Similaammation A, no posHF ratio E and F. HF ratio .The role of the pCC in mediating effects of inflammation on diastolic blood pressure is also worthy of comment. Though the pCC is not formally part of the central autonomic network and indeed shows few (if any) direct projections to brain stem pre-autonomic and cardiovascular regulatory cell groups, several studies have shown changes in pCC activity in conjunction with stressor evoked autonomic and cardiovascular reactions . This apTo conclude, to date explanations for why HRV may be reduced in depression have typically adopted cognitive explanations for example, an inability to disengage threat detection that then serves to perpetuate worry and hyper-vigilance, even when no real threat exists . HoweverThe present study is constrained in the degree to which we can extrapolate the findings linking sickness responses and bodily inflammation to changes in mood and autonomic states reported in primary idiopathic depression. Firstly, the observed autonomic responses to Typhoid vaccination do not completely replicate the pattern of cardiac parasympathetic withdrawal most commonly reported in depression  and othe


Pulmonary hypertension (PH) is an important cause of heart failure in chronic obstructive pulmonary disease (COPD). The pro brain natriuretic peptide N-terminal (NT-proBNP) has been suggested as a noninvasive marker to evaluate ventricular function. However, there is no evidence to support the use of NT-proBNP in monitoring the benefits of vasodilators in COPD induced PH. Thus, we used NT-proBNP as a biomarker to evaluate the effect of oral vasodilators on cardiac function in COPD-induced PH. Forty clinically-stable PH patients were enrolled with history of COPD, normal left ventricular ejection-fraction (LVEF), right ventricular systolic pressure (RVSP) > 45 mmHg and baseline blood NT-proBNP levels >100 pg/mL. Patients were randomized into two groups, one group received sildenafil and second group were given amlodipine for two weeks. NT-proBNP and systolic pulmonary arterial pressure (systolic PA-pressure) were measured at the beginning and the end of study. Mean NT-proBNP level in the first group was 1297 ± 912 pg/mL before therapy and 554 ± 5 pg/mL after two weeks drug therapy, respectively. Similarly, in second group NT-proBNP level was 1657 ± 989 pg/mL and 646 ± 5 pg/mL before and after treatment. Amlodipine or sildenafil significantly reduced NT-proBNP levels in COPD-induced PH patients (p < 0.05). Our study shows that amlodipine and sildenafil have a similar effect on NT-proBNP levels. In both groups NT- proBNP levels were significantly reduced after treatment. Therefore, our findings support the potential benefits of treatment with vasodilators in COPD induced PH. Pulmonary hypertension, Chronic obstructive pulmonary disease, NT-proBNP, Amlodipine, Sildenafil Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide with an increasing prevalence . PulmonaCurrently, there is no specific therapy for PH associated with COPD. Long-term Oxygen administration has been shown partially to reduce the progression of PH in COPD. Despite this treatment, pulmonary arterial pressure (PAP) not often returns to normal values and the structural abnormalities of pulmonary vessels remain untouched . SpecifiNatriuretic peptides are hormones secreted by heart in response to hemodynamic stress and structural abnormalities of the heart. Moreover, circulating N-terminal of pro brain natriuretic peptide (NT-proBNP) concentration has recently been shown to correlate well with survival and echocardiography-derived measures of right ventricular (RV) function in PH . In addiWe assessed NT-proBNP levels along with systolic pulmonary arterial pressure (systolic PA-pressure) to monitor RV function in COPD-induced PH patients. Also for the first time, response to oral vasodilators (sildenafil and amlodipine) was evaluated by NT-proBNP in these patients.This prospective, randomized, open-label parallel group study was carried out at the National Research Institute of Tuberculosis and Lung Disease (NRITLD), Masih Daneshvari Hospital, Tehran, Iran, between May 2008 and July 2009.Inclusion criteria were diagnosis of COPD patients without exacerbation or hospital admission in the past two months, 18 to 75 years of age, right ventricular systolic pressure (RVSP) greater than 45 mmHg and baseline blood NT-proBNP levels above 100 pg/mL. Patients data including past medical history, blood tests results and transthoracic echocardiogram. Patients with coexisting conditions likely to elevate NT-proBNP levels, such as pulmonary embolism , ischemiTreatment started at the time of randomization (baseline) for two weeks. In group (A) patients received sildenafil25-50 mg two times daily and in group (B) patients took amlodipine 2.5-7.5 mg once daily. These dosage ranges of medication were decided by cardiologist (BSK) based on blood pressure and patient tolerance. NT-proBNP and systolic PA-pressure levels were measured before and after the two weeks of drug administration.Diagnostic testsPatients were evaluated by at least two physician board-certified internal medicine specialists during outpatient visits. The diagnosis of COPD was based on clinical history, physical examination and spirometric criteria according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines . Then stEchocardiographyEchocardiographic studies were performed by a cardiologist, experienced in evaluation of pulmonary heart disease and parameters from Doppler analysis, M-mode and two-dimensional trans-thoracic echocardiographies were used. Furthermore, we measured the peak velocity of the tricuspid regurgitant signal by continuous wave doppler and calculated the RVSP with the modified Bernoulli equation, which is believed to reflect systolic PA-pressure in the absence of RV outflow tract obstruction. Theoretically, calculation of mPAP from systolic PA-pressure (PASP) is possible, {mPAP = (0.61×PASP) + 2 mmHg} .NT-proBNP measurementAfter the echocardiography, eligible patients selected to measure blood NT-proBNP levels. Heparinized venous whole blood samples  from each patient were analyzed for NT-proBNP, using a validated, commercially available immunoassay , using established methodology . ResultsData analysisData were expressed as mean ± SD and median where appropriate, and analyzed using SPSS 16.0 for Windows. All variables were tested for normal distribution with the Kolmogorov-Smirnov test. Dependent of their distribution, Wilcoxon’s test was used to determine if there were significant differences among NT-proBNP levels after two weeks drug therapy in the two different groups  and comparison between sildenafil group and amlodipine group was performed using the Mann-Whitney U-test .Spearman›s correlation analyses were performed to investigate significant correlations and Kruskal-Wallis test was used to determine if there were significant differences among baseline values of two different groups. A value of p < 0.05 was considered significant.The study was approved by the medical ethics committee of the Shahid Beheshti University of Medical Science and written informed consent was obtained from all patients.A total of 1182 patients, with the diagnosis of COPD were screened for enrolment. Forty six patients were eligible and underwent randomization. Six patients withdrew from the study. Two patients in each group discontinued because of acute COPD exacerbation. Moreover, two patients in group (B) excluded because their follow up session was taken more than two weeks. Finally, forty clinically-stable COPD patients with PH completed the follow up correctly .Baseline CharacteristicsThe mean ± SD age of the studied population was 61.6 ± 7.8 with a range of 48-75 years and the majority (77%) of patients was male. A comparison of baseline parameters between two groups demonstrated no significant difference in age, gender, smoking, systolic PA pressure and NT-proBNP , reflectThe baseline clinical characteristics of study population are summarized in NT-proBNP and Oral vasodilators effectsBoth sildenafil and amlodipine reduced NT-proBNP levels significantly in patients with COPD-induced PH after two weeks of treatment . Also, tIn group A which sildenafil was given, plasma NT-proBNP concentration was reduced after two weeks treatment significantly. Median of NT-proBNP value was 942 pg/mL and 273 pg/mL (p < 0.001) at baseline and after intervention, respectively. Like NT-proBNPs a significant decrease was identified in systolic PA-pressure .In group B that patients treated with amlodipine, there was a significant reduction in plasma NT-proBNP concentration after two weeks drug therapy was seen. The baseline median value was 1760 pg/mL before treatment and 458 pg/mL after treatment (p < 0.001). Similar to NT-proBNP, the fall in systolic PA-pressure was statistically significant in both group .The NT-proBNP level of patients in both groups was significantly decreased after receiving the study medications. However, comparison between group A and B indicated no significant difference between sildenafil and amlodipine in lowering the NT-proBNP levels (p = 0.185) .Relationship between change in NT-proBNP and echocardiography findingsThere was a significant correlation between pre-treatment baseline NT-proBNP levels and baseline systolic PA- pressure . Also the correlation between estimated NT-proBNP and systolic PA-pressure levels after two weeks treatment was significant .MortalityThe high plasma NT-proBNP concentration (>3000 pg/mL) was the reason for exclusion of four patients (two patient in group A and two patient in group B). The two patients in group B died in the hospital during the period less than three weeks.Results from our study pointed, NT-proBNP and systolic PA-pressure levels in COPD induced PH patients after a two-week drug therapy with sildenafil or amlodipine were reduced statistically significant. In fact, decreasing NT- proBNP levels may be an indicator of the efficacy of treatment with amlodipine or sildenafil on improving RV function in COPD induced PH. NT-proBNP level increases due to pulmonary hypertension and RV overload . LowerinTo compare the effect of these drugs in reducing NT-proBNP levels, no significant difference was observed between sildenafil and amlodipine.et al.  test and a cardiopulmonary exercise test (CPET) should be performed.


Cardiac-surgery-associated-acute-kidney-injury (CSA-AKI) is associated with increased morbidity and mortality. Recent data from patients undergoing on-pump coronary artery bypass grafting suggest that a perioperative infusion of sodium-bicarbonate may decrease the incidence of CSA-AKI. The present study aims to analyze the renoprotective effects of a 24h infusion of sodium-bicarbonate in a large, heterogeneous group of cardiac surgical patientsStarting in 4/2009, all patients undergoing cardiac surgery at our institution were enrolled in a prospective trial analyzing the relationship between preoperative cerebral oxygen saturation and postoperative organ dysfunction. We used this prospectively sampled data set to perform a cohort analysis of the renoprotective efficiency of a 24h continuous perioperative infusion of sodium-bicarbonate on the incidence of CSA-AKI that was routinely introduced in 7/2009. After exclusion of patients with endstage chronic kidney disease, off-pump procedures, and emergency cases, perioperative changes in renal function were assessed in 280 patients treated with a perioperative infusion of 4 mmol sodium-bicarbonate / kg body weight in comparison with a control cohort of 304 patients enrolled from April to June in this prospective cohort study.Postoperative changes in urine flow, plasma creatinine, estimated creatinine clearance, and the need for renal replacement therapy were determined according to AKI injury network criteria. Concomitantly, hemodynamics, treatments, complications, and clinical outcomes were recorded. Univariate statistical analyses were performed para- and nonparametrically, as appropriate.With the exception of a lower prevalence of a history of myocardial infarction and a lower preoperative use of intravenous heparin in the bicarbonate-group, no significant between group differences in patient demographics, surgical risk, type, and duration of surgery were observed. Patients in the bicarbonate group had a lower mean arterial blood pressure after induction of anesthesia, needed more fluids, more vasopressors, and a longer treatment time in the high dependency unit. Despite a higher postoperative diuresis, no differences in the incidence of AKI grade 1 to 3 and the need for renal replacement were observed.Routine perioperative administration of sodium bicarbonate failed to improve postoperative renal function in a large population of cardiac surgical patients. Acute kidney injury (AKI) is a frequent complication in patients undergoing cardiac surgery ,2. With Recent work suggests that the renal excretion of hemo- and myoglobin, as a consequence of the destruction of blood cells during cardiopulmonary bypass and tissue injury during prolonged periods of hypoperfusion, and the subsequent development of a pigment nephropathy, may play a pathophysiologically important role in CSA-AKI . In suppWith respect to the enormous impact of postoperative renal dysfunction on outcome in cardiac surgical patients, the sound pathophysiological basis, and positive historical experiences with urine alkalization in our center we decided not to await the results of the ongoing multicentre trial and implemented the concept of perioperative BIC infusion in July 2009 at our institution. With respect to the fact that since April 2009 almost all patients undergoing cardiac surgery at the University of Lübeck were enrolled in a prospective observational trial analyzing the association between preoperative cerebral oxygen saturation and postoperative organ dysfunction, we chose to use this database also to analyze the effects of routine BIC application on the perioperative changes in renal function and the incidence of AKI in this prospective, observational cohort study.Following approval by the local ethical committee , all patients scheduled for cardiac surgery at the University of Lübeck from 1 April 2009 to 31 December 2009 were screened for participation in a prospective, observational trial on the relationship between preoperative cerebral oxygenation and postoperative organ dysfunction. The only exclusion criterion was age less below 18 years. Written informed consent was obtained from all elective and urgent patients as well as emergency patients who were able to communicate. In the case of sedated and/or intubated patients scheduled for emergency surgery, consent was obtained from the next of kin and reconfirmed after recovery.From July 2009, all patients were treated with a perioperative infusion of BIC, and the treatment was maintained until the first results of the present study were available in December 2010. Following approval by the local ethical committee of amendment 5 to the primary request , we specifically analyzed the perioperative changes in renal function and general patient outcomes according to the use or non-use of BIC. After exclusion of patients with end-stage chronic kidney disease, off-pump procedures, and emergency cases, perioperative changes in renal function were assessed in 280 patients treated with BIC in comparison with a control cohort (CON) of 304 patients enrolled from April to June. In addition to the standard treatment, plasma samples for determination of N-terminal pro B-type natriuretic peptide (NTproBNP) and high-sensitivity troponin-T (hsTNT) were drawn immediately before surgery.The perioperative infusion of BIC was adapted from Haase and coworkers [(7)]. A bolus of 0.5 mmol/Kg body weight (BW) in a balanced electrolyte infusion (500 ml) was infused within 30 minutes immediately after induction of anesthesia. Thereafter, a maintenance infusion of 0.15 mmol/Kg BW/h in 500 ml dextrose in water (5%) was applied within 24 h, giving a total dose of 4 mmol BIC/Kg BW during 24 h. Anesthesiological, surgical, and intensive care treatment followed the standardized algorithms established at the Department of Anesthesiology and the Department of Thoracic Vascular and Cardiac Surgery of the University of Lübeck.® 5100 monitor  were applied bi-hemisperically before induction of anesthesia. Baseline ScO2 was determined in the resting state when breathing room air. General anesthesia was induced with sufentanil 0.5 μg/Kg BW, etomidate 0.2 to 0.4 mg/Kg BW and maintained at 0.8 to 1.0 minimal alveolar concentration of sevoflurane and remifentanyl at 0.2 to 0.4 μg/Kg BW/min, with the goal of early postoperative extubation. Muscle relaxation was achieved with rocuronium bromide 0.6 mg/Kg BW. During cardiopulmonary bypass (CPB), propofol at a dose of 4 to 5 mg/Kg BW/h was applied, since at that time volatile anesthetics could not be given via the CPB circuit. After surgery, all patients were transferred to the ICU, and after normothermia had been achieved, were weaned from the respirator as soon as possible.Following oral premedication with 3.75 to 7.5 mg midazolam, and transfer to the operating room, sensors for the determination of cerebral oxygen saturation (ScO2) with an INVOSHemodynamic therapy aimed at a mean arterial blood pressure (MAP) between 60 and 90 mmHg, a heart rate (HR) between 60 and 90 bpm, a central venous pressure (CVP) between 10 and 15 mmHg, and central venous oxygen saturation (ScvO2) greater than 70%. In patients monitored with a pulmonary artery catheter, hemodynamic therapy was titrated to achieve a cardiac index > 2.2 l/min/m2 and mixed venous oxygen saturation (SvO2) greater than 65% . Pulmona®, Fresenius, Germany; Gelafundin®, BBraun, Melsungen, Germany) fluids, as suggested by a recent guideline [Fluid therapy was performed by balanced cristalloid  and colloidal (Volulyteuideline .All surgeries were performed with CPB in moderate or deep hypothermia (according to the preferences of the surgeon and the scheduled type of surgery). Cardioplegic arrest was achieved by blood cardioplegia and repeated every 20 minutes. In coronary-artery bypass grafting (CABG), a single crossclamp was generally used. Non-pulsatile perfusion was performed during CPB. Pump flow, oxygen flow, and MAP were adjusted to maintain ScO2 levels higher than 50% absolute.Patients were discharged from the ICU to the intermediate care unit (IMC) if they were hemodynamically stable with only moderate inotropic and/or vasopressor support and were breathing spontaneously without the need for non-invasive ventilation. They were discharged to the surgical ward if they had been completely weaned from vasoactive or inotropic drugs, showed no signs of a relevant organ dysfunction , and were free of delirium.A perioperative myocardial infarction was defined as a relevant increase in myocardial necrosis markers (creatinine-kinase and creatinine-kinase MB fraction) in combination with the development of typical electrocardiographic findings or the detection of a new wall motion abnormality by echocardiography.Indications for renal replacement therapy were as follows: potassium equal to or higher than 6 mmol/L despite forced diuresis or prolonged treatment with glucose-insulin solution; fluid overload with imminent or present extrarenal organ dysfunction not responsive to moderate doses of diuretics , severe low cardiac output state with persistent oliguria despite, or inadequate reaction to a bolus of a loop diuretic .Renal replacement therapy was performed as veno-venous hemodiafiltration in postdilution mode with a blood flow of 150 to 200 ml/min, an ultrafiltration dose of 20 ml/Kg BW/h, and a dialysis dose of 15ml/Kg/h.P-value < 0.05 was considered to indicate statistical significance.Data entry and analysis were performed with MedCalc 12.1.4. for Windows. Following Kolmogorov-Smirnov testing for normality of distribution, data were analyzed by parametric and non-parametric tests, as appropriate. Accordingly, if not stated otherwise, data are presented as mean and 95% confidence interval for the mean, or median and 95% confidence interval for the median. A The severity of postoperative kidney dysfunction was quantified according to the criteria of AKI as suggested by the Acute Kidney Injury Network . AdditioWith the exception of a lower prevalence of a history of myocardial infarction (18.6% vs. 26.3%) and a lower preoperative use of intravenous heparin in the BIC group, the study cohorts were highly comparable regarding baseline demographics, surgical procedures, and surgical core data . The specific changes in plasma creatinine, eGFR and the grading according to the Acute Kidney Injury Network criteria are depicted in Table Patients in the BIC group had a higher diuresis within the first 24 h after surgery. No differences were observed in the use of diuretics Table . Renal rDespite comparable postoperative ventilation times, duration of treatment in the ICU and in the high dependency unit (HDU) were significantly prolonged in the BIC group Table . No diffAKI is not only a frequent complication in cardiac surgical patients  but has Recently, Haase and coworkers have elegantly delineated a pathophysiological line of evidence that the severity of the renal insult induced by on-pump cardiac surgery may, at least in part, be related to the degree of hemoglobinuria: the histological features of CSA-AKI resemble the pigment nephropathy typically observed during rhabdomyolysis . Since aIn contrast to these promising findings, the results of the present prospective observational cohort study show that, in a heterogeneous patient population and under the real life conditions of a University hospital, perioperative treatment with BIC does not reduce the incidence of CSA-AKI as measured by postoperative changes in creatinine, and the need for dialysis. Moreover, it is associated with clearly unwarranted effects like a decrease in arterial blood pressure (during the bolus application of BIC), an increased need for fluids and vasopressors, and an increased need for treatment in the HDU.The BIC dose chosen at our institution was comparable to the dose used by Haase and coworkers in their pilot study . HoweverWith respect to the observational nature of our study, we cannot completely rule out the possibility that the adverse effects observed during the intervention period were related to other, unmeasured variables. However, the patient groups were ideally matched at baseline; not only with respect to conventional demographic factors and surgical procedures but also regarding the plasma levels of established cardiovascular risk markers. The patients were closely followed during the perioperative course, and a relevant number of patients were monitored invasively with a pulmonary arterial catheter to determine the cardiac index and SvO2. We are also not aware of any other clinical factor that was changed during this time: neither the introduction of another, new clinical treatment nor major changes in the treatment team. Thus it is rather likely that the observed adverse effects in the intervention period were indeed related to the use of bicarbonate infusion, that is, alkalization, despite only achieving minimal changes in maximal plasma pH.Data show that BIC is frequently used in cardiac surgical patients to treat acidosis, especially during cardiopulmonary bypass. Despite this, few data are available on the short- and long-term hemodynamic effects of BIC. Tripathi and coworkers observed a biphasic response after the infusion of 1 mmol BIC/Kg BW during steady state conditions during CPB with an immediate venous pooling (leading to a decrease in the CPB reservoir volume), followed by a moderate increase in MAP. In contrast, observations in patients with end-stage renal disease show that higher dialysate bicarbonate concentrations lead to a decrease in arterial blood pressure during dialysis , an effeSince the differences in maximal pH between the study groups were rather small (0.1 pH difference) despite being statistically significant, one may assume that the lack of a nephroprotective effect of bicarbonate infusion may be related to the fact that no adequate alkalization was achieved. It is of note that Haase and coworkers observed a mean difference in pH of 0.7 (7.38 to 7.45) [As an important difference in comparison with the previous pilot study  we did nComparably, we cannot rule out that the minor effect of the BIC infusion on plasma pH in our study in comparison with Haase's work may be related to the different types of crystalloid infusions used: 0.9% sodium chloride in the Australian setting  and a baDespite all efforts to follow the patients meticulously and to rule out other factors that may have influenced our results, the design of this study as an observational cohort study has a substantial risk of bias. The present ongoing BIC-NC study  will help to elucidate further, the risks and benefits of using BIC to prevent AKI in patients undergoing cardiac surgery.With respect to the observational nature of this study we did not perform an a priori power analysis to determine if the sample size is adequate. However, we enrolled more patients than planned for the BIC-NC study and additionally tested the endpoint, namely, 25% increase in plasma creatinine, suggesting that our dataset is adequately powered.In conclusion, the present prospective observational trial failed to reproduce the beneficial effects of a 24-h perioperative infusion of 4 mmol/Kg BIC on the incidence of AKI in patients undergoing cardiac surgery, that were recently shown in a small pilot trial. Routine treatment in a heterogeneous cohort with BIC was associated with an increased need for fluids and vasopressors. If this is a direct effect of BIC infusion, or the indirect effect of an associated treatment with balanced crystalloid solutions containing the vasodilating buffer acetate, merits further investigation.• The routine perioperative infusion of 4 mmol /Kg BW sodium failed to reduce the incidence of acute kidney injury and the need for renal replacement therapy in a heterogeneous cohort of cardiac surgical patients.• Treatment with BIC was associated with hypotension, a higher need for vasopressors, and a prolonged stay in the HDU but had no other significant adverse effects on non-renal morbidity and 30-day mortality.AKI: acute kidney injury; BIC: sodium bicarbonate; CABG: coronary artery bypass grafting; CI: cardiac index; CON: control (non-intervention) group; CPB: cardiopulmonary bypass; CSA-AKI: cardiac surgery-assocaiated acute kidney injury; CVP: central venous pressure; eGFR: estimated glomerular filtration rate; HDU: high dependency unit; HR: heart rate; hsTNT: high-sensitivity troponin T; ICU: intensive care unit; IMC: intermediate care unit; MAP: mean arterial pressure; NTproBNP: N-terminal pro B-type natriuretic peptide; PAP: pulmonary arterial pressure; RRT: renal replacement therapy; ScO2: cerebral oxygen saturation; ScvO2: central venous oxygen saturation; SvO2: mixed venous oxygen saturation.The authors declare that they have no competing interests.MH, HH, JH and TH designed the study, supervised the statistical analyses and drafted the manuscript. MS, YN, JG, MK, and HP collected the data and performed the statistical analyses. All authors read and approved the final manuscript.


Although hypertension is, in most cases, a controllable major risk factor in the development of cardiovascular disease, studies have demonstrated that hypertension remains poorly controlled in Portugal. Our aim was to evaluate the covariates associated with poor blood pressure (BP) control in a Portuguese hypertensive population.P = 0.004), medication nonadherence , and diabetes . Predictors of medication nonadherence were: unawareness of target BP values , a report of drug side effects , lack of BP monitoring  and unawareness of medication indications , and of hypertension risks .We conducted a cross-sectional survey in a hospital hypertension outpatient clinic, located in the Eastern Central Region of Portugal. Patients attending the clinic from July to September 2009 were asked to participate in a structured interview including medication adherence and knowledge about hypertension. Eligible participants were all adults aged 18 or over with an established diagnosis of arterial hypertension and had been on antihypertensive drug treatment for at least 6 months. Exclusion criteria were dementia, pregnancy, and breastfeeding. Detailed clinical information was prospectively obtained from medical records. A total of 197 patients meeting the inclusion criteria and consenting to participate completed the interview. Of these, only 33.0% had their BP controlled according to the JNC 7 guidelines. Logistic regression analysis revealed three independent predictors of poor BP control: living alone (OR = 5.3, Poor medication adherence, lack of information about hypertension, and side effects should be considered as possible underlying causes of uncontrolled BP and must be addressed in any intervention aimed to improve BP control. Hypertension is a major risk factor in the development of cardiovascular disease and one of the most important public health problems in Portugal affecting over 3 million Portuguese adults (about 30% of the Portuguese population). In well-2The Eastern Central Region of Portugal possesses a university teaching hospital at Covilhã, named Cova da Beira Hospital Centre, with an important secondary care hypertension/dyslipidemia outpatient clinic, which serves a significant hypertensive population of the District of Castelo Branco. To better understand the unsatisfactory levels of BP control of this hypertensive population and focus efforts on improving them, it would be useful to know the extent to which hypertensive patients with different risks for vascular complications are not satisfactorily controlled and to identify some possible factors that may be involved in inadequate BP control. Accordingly, we conducted a cross-sectional study to evaluate the level of BP control in hypertensive patients attending the mentioned hospital hypertension/dyslipidemia outpatient clinic and to recognize some factors that may underlie insufficient BP control and poor medication adherence.In July–September 2009, we conducted a cross-sectional survey in a secondary care hypertension/dyslipidemia clinic in the university teaching hospital of Cova da Beira Hospital Centre, Covilhã, District of Castelo Branco, located in the Eastern Central Region of Portugal. This outpatient clinic is one of the most important clinics of this region in Portugal in the field of hypertension/dyslipidemia and serves a significant hypertensive population of Covilhã Area, with a population of 35 thousand inhabitants.All hypertensive patients attending the medical clinic during that period were asked to complete the structured interview. Patients were asked to complete a structured questionnaire on demography, medication adherence, and knowledge about target BP values, hypertension risks, indications of antihypertensive medication, and the presence of drug side effects. Subjects were also asked whether they used a home BP monitoring device and/or whether they measure their BP regularly. The study was approved by the Institutional Ethics Committee for the use of humans in research, and written informed consent was obtained from all participants before their enrolment in the study.Eligible participants were all adults aged 18 or over with an established medical diagnosis of arterial hypertension (BP measurements in the clinic of systolic BP (SBP) ≥140 mmHg and/or diastolic BP (DBP) ≥90 mm Hg). Furthermore, all included patients had been on established antihypertensive drug treatment for at least 6 months. Exclusion criteria were dementia, pregnancy, and breastfeeding.BP was measured in a seated position after a 5-min rest period, using a mercury sphygmomanometer or semi-automatic device, the mean of two consecutive measurements being recorded. According to the JNC 7 guidelines, hypertensive patients without diabetes and CKD with BP <140/90 mmHg were considered to have their BP controlled. For hypertensive patients with diabetes or CKD, BP control was defined as BP measurements <130/80 mmHg.et al.[Assessment of antihypertensive medication adherence was determined using the instrument validated by Morisky et al.5 Poor meClinical data for this study, including BP measures, medications prescribed, and medical problems, were prospectively obtained from the Hospital Electronic Medical Records (HEMR) database. The HEMR database of Cova da Beira Hospital Centre is comprised of detailed patient-level clinical and administrative information of all patients that have used this hospital at least once. Available information includes patient demographics, medical problems, various measures of physiological status, and medications prescribed. This database is authorized by the Portugal Department of Health, the government department responsible for public health issues, and patient data confidentiality was ensured.2 -test were used. Multivariate analyses were conducted using logistic regressions with the forward likelihood ratio (Forward:LR) selection algorithm. All statistical analyses were carried out using SPSS for Windows, version 17.0 , and a P-value of less than 0.05 was considered to indicate statistical significance.Demographic variables, clinical data, and BP values of hypertensive patients included in the study, as well as prescribing metrics were examined on a descriptive basis and expressed as the mean ± SD, frequency, and percentages. To test for differences between categorical variables χA total of 222 patients attended the medical clinic during the recruitment period (from July 2009 to September 2009), and all were assessed for eligibility. Of these, 17 were excluded from the study because they did not meet the inclusion criteria, 1 was excluded because of breastfeeding, and 7 were excluded because they declined to participate (they did not sign the informed consent). Thus, a total of 197 (89%) hypertensive patients met the inclusion criteria and consented to participate .The overall mean age of the included patients was 60 ± 12 years, 40.1% being male and 59.9% female . Among tP = 0.009). In all, 37.1% (73/197) patients attained BP values <140/90 mmHg.Overall, the mean systolic BP of the 197 hypertensive patients included in our analysis was 141.8 ± 16.5 mmHg, and the mean diastolic BP was 85.8 ± 11.80 mmHg, with 33.0% (65/197) patients attaining controlled BP according to JNC 7 guidelines. Among patients with neither diabetes nor CKD, 39.2% had their BP controlled, whereas among patients with one or both of these pathologies this figure was 11.4% (P < 0.001), marital status , and diabetes  were the independent variables that significantly influenced BP control. Using the logistic regression coefficients (ln(OR)) for those covariates, the following significant logistic regression model (G2 (3) = 46.054; P < 0.001; X2 HL(4) = 4.152; P = 0.386; R2 CS = 0.208; R2 N = 0.290; R2 MF = 0.184, where G2 is the likelihood-ratio goodness-of-fit statistic, X2 HL is the Hosmer and Lemeshow statistic, R2 CS is the Cox and Snell R square, R2 N is the Nagelkerke R square, and R2 MF is the McFadden R square) was obtained:Forward:LR logistic regression revealed that the covariates medication adherence  where Pb is the probability of a given patient to have uncontrolled BP, ADH is medication adherence , MS is marital status , and DIAB is diabetes .P < 0.001).This model has acceptable sensitivity (77.3%) and specificity (63.1%), as well as an acceptable discrimination power , reporting of drug side effects , measuring BP regularly , knowledge of drug indications , and knowledge of hypertension risks  were the independent variables that significantly influences medication adherence. Using the logistic regression coefficients (ln(OR)) for those covariates, the following significant logistic regression model (G2 (5) = 54.446; P < 0.001; X2 HL (7) = 2.448; P = 0.931; R2 CS = 0.241; R2 N = 0.322; R2 MF = 0.200) was obtained:Of the three covariates figuring in Eq. (1), medication adherence is the independent variable more likely to be favorably influenced by a health care professional team in order to enhance BP control. Thus, we determined the covariates that significantly influence the dependent variable medication adherence. Forward:LR logistic regression revealed that knowledge of target BP  where Pb is the probability of a given patient to be nonadherent to medication, TBP, knows target BP ; SE, reports side effects ; BPR, measures BP regularly ; DI, knows drug indications ; and HTR, knows hypertension risks .P < 0.001).This model also revealed to have acceptable sensitivity (71.6%) and specificity (72.6%), as well as an acceptable discrimination power  are amenable to improvement by team-based health care professionals’ interventions in order to increase medication adherence and, thereby, BP control.P = 0.009) in patients without diabetes or CKD (39.2%) when compared to patients with diabetes and/or CKD (11.4%). To the best of our knowledge, this prospective study presents for the first time the percentage of treated and controlled hypertensives, according to the JNC 7 guidelines, in a Portuguese subpopulation. It should be noted that the reported levels of BP control can vary greatly depending on the study population, methods, and time frame.[et al., reported that 39% of patients had BP figures <140/90 mmHg and only 13% of the diabetic population were normalized according to the international recommendations (<130/80 mmHg).[et al.[et al.[et al.[et al., in a middle-West French treated hypertensive population, for both patients without diabetes and CKD and patients with these pathologies.The results presented in this study describe some demographic and clinical characteristics of hypertensive patients attending the medical consultation of hypertension/dyslipidemia in a university teaching hospital located in the Eastern Central Region of Portugal, focusing on the level of hypertension control and antihypertensive medication adherence. According to a survey conducted in 2003, of the tme frame.9 In one me frame. In a regd/or CKD .4%. To tl.[et al. conducteThe logistic regression analyses of the study population revealed that the covariates medication adherence, marital status and diabetes significantly influence BP control, such that the probability of a nonadherent, unwed, diabetic patient to have uncontrolled hypertension is 98.6%. At the other end, the probability of an adherent, married, nondiabetic patient to have uncontrolled hypertension is only 39.3%. Surely, there are more unstudied independent variables that significantly influence BP control . For example, the possible existence of clinical inertia and undertreatment must be analyzed in patients with diabetes or CKD. However, sensitivity, specificity, and ROC curve analysis revealed an acceptable model performance.Of the three covariates significantly influencing BP control, the variable most likely to be favorably influenced by team-based health care professionals’ interventions is medication adherence. In patients with hypertension, medication nonadherence is a significant, often unrecognized, risk factor that contributes to poor BP control, thereby contributing to the development of further vascular disorders such as heart failure, coronary heart disease, renal insufficiency, and stroke. Antihype17Logistic regression revealed that knowledge of target BP values, the presence of drug side effects, measuring BP regularly, knowledge of drug indications, and knowledge of hypertension risks are the independent variables that significantly influence medication adherence. According to our logistic regression model (Eq. (2)), the probability of a hypertensive patient ignoring target BP values, drug indications and hypertension risks, reporting drug side effects and not monitoring BP regularly to be nonadherent is 97.4%. On the contrary, the probability of a hypertensive patient knowing the target BP values, drug indications and hypertension risks, not presenting drug side effects and monitoring BP regularly to be nonadherent is only 17.6%.P = 0.020) 59.4% were aware of their target BP figures (systolic and diastolic). Self and/or regular BP measurement is useful for the assessment of the treatment effects by the doctor and is valuable for the patients in improving the management of their high BP. However, as many patients (40.6%) do not know their target BP values they cannot accurately report whether it is controlled. Therefore, a major implication of our study is the need for education of patients to their target BP figures so that they can correctly identify whether it is elevated or controlled. Likewise, our findings also suggest the need to improve patient awareness of the cardiovascular risks of hypertension and of the therapeutic indications and usefulness of antihypertensives. It is worth noting that even though these patients have had hypertension for a long period (average number of years in antihypertensive drug treatment was 9.8 ± 7.7 years), their knowledge is inadequate. Recent research points to the need to improve hypertension knowledge and awareness in order to increase medication adherence and BP control.[Although a significant percentage (70.6%) of patients reported to measure BP regularly, only P = 0.0 59.4% we control. Continui control. Adverse  control. However, control. DiscussiSeveral features of our study deserve further comment. To our knowledge, this is the first Portuguese study examining barriers to BP control in treated hypertensive outpatients in the Eastern Central Region of Portugal. The study may be relevant to similar Caucasian populations in Portugal and other European countries. Other strengths were the high response rate and the 96.6% completion of questionnaires. The limitations are the size of the study, and the evaluation of BP control based on the measurements performed in one single medical appointment. These BP measurements may or may not be representative of the adequacy of BP control in hypertensive patients. We also were unable to obtain objective measurements of patient compliance  or to assess the attitudes of the physicians and nurses toward patients. Behavioral models suggest that the most effective therapy prescribed by the most careful physician will control hypertension only if the patient is motivated to take the medication as directed. Motivati24In conclusion, this study provides a framework for identifying hypertensive patients who are at high risk of poor BP control and since many of the identified factors are modifiable, they signal opportunities to improve BP control in clinical practice. Poor medication adherence and patient unawareness about target BP values, hypertension risks and antihypertensive drug indications, as well as the presence of drug side effects and lack of regular BP monitoring should be considered as possible underlying causes of inadequately controlled BP and must be addressed in any intervention aimed to improve BP control. Strategies to improve medication adherence must be reinforced. Self-monitoring with validated BP devices should be encouraged. Patients with poor knowledge of the goal of their hypertension therapy should be informed about their target BP, to enable them to participate more fully in their own management. To achieve the crucial objective of improving health by controlling high BP, it is important to fully understand the current status of patient knowledge, awareness, and attitudes with respect to hypertension, medication, and lifestyles. It is necessary to understand these patient factors to develop effective strategies and team-based health care professionals’ interventions that enroll the patient as a participant in the management of his hypertension.


Cardiovascular disease morbidity-mortality is greater in people with type 2 diabetes mellitus or metabolic syndrome. The purpose of this study was to evaluate the yearly evolution of organ damage markers in diabetes or metabolic syndrome, and to analyze the associated factors.An observational prospective study was carried out in the primary care setting, involving 112 patients: 68 diabetics and 44 subjects with metabolic syndrome, subjected to 12 months of follow-up. Measurements: traditional cardiovascular risk factors  and) and non-traditional risk factors ; subclinical vascular , cardiac (Cornell voltage-duration product), renal organ damage , and antihypertensive and lipid-lowering drugs.At baseline, the diabetics presented a mean age of 59.9 years, versus 55.2 years in the subjects with metabolic syndrome (p = 0.03). Diastolic blood pressure, total cholesterol and HDL-cholesterol were lower among the patients with diabetes, while blood glucose and HbA1c, as well as antihypertensive and lipid-lowering drug use, were greater. At evaluation after one year, the diabetics showed a decrease in BMI (-0.39), diastolic blood pressure (-3.59), and an increase in fibrinogen (30.23 mg/dL), ankle/brachial index (0.07) and the number of patients with ankle/brachial index pathologic decreased in 6. In turn, the patients with metabolic syndrome showed an increase in HDL-cholesterol (1-91 mg/dL), fibrinogen (25.54 mg/dL), Cornell voltage-duration product (184.22 mm/ms), ankle/brachial index (0.05) and the use of antihypertensive and lipid-lowering drugs, and a reduction in serum glucose (3.74 mg/dL), HOMA, systolic (-6.76 mmHg), diastolic blood pressure (-3.29 mmHg), and pulse wave velocity (-0.72 m/s). The variable that best predicted a decrease in pulse wave velocity in subjects with metabolic syndrome was seen to be an increase in antihypertensive drug use.The annual assessment of cardiovascular risk factors and the decrease in pulse wave velocity was more favorable in the patients with metabolic syndrome, probably influenced by the increased percentage of subjects treated with antihypertensive and lipid lowering drugs in this group. Cardiovascular disease morbidity-mortality is greater in people with type 2 diabetes mellitus (T2DM) or metabolic syndrome -4. The pWe postulate that the evolution of the different risk factors and target organ damage is similar in both groups, since the antihypertensive drugs, lipid lowering drugs and metformin with beneficial effects upon blood pressure, lipid profile and target organ damage, are used in greater percentages in the group of patients with T2DM.The purpose of this study was to evaluate the yearly evolution of organ damage markers in diabetes or metabolic syndrome, and to analyze the associated factors.A prospective observational study was carried out in a primary care setting. Using consecutive sampling, we included 112 patients with type 2 diabetes mellitus (T2DM) (n = 68) (defined using the American Diabetes Association criteria ) or metaA detailed description has been published elsewhere of how the clinical data were collected, the anthropometric measurements were made, blood pressure was recorded, TOD was assessed, and the analytical parameters were obtained .Office or clinical blood pressure measurement was obtained by performing three measurements of systolic (SBP) and diastolic blood pressure (DBP), using the average of the last two, with a validated OMRON model M7 sphygmomanometer , and following the recommendations of the European Society of Hypertension . The meaCarotid ultrasound to assess IMT was performed by two investigators trained for this purpose before starting the study. The reliability of assessment was evaluated before the study, using the intraclass correlation coefficient, which showed values of 0.974 (95%CI: 0.935 to 0.990) for intra-observer agreement on repeated measurements in 20 subjects, and 0.897 (95%CI: 0.740 to 0.959) for inter-observer agreement. According to the Bland-Altman analysis, the limit of inter-observer agreement was 0.022 (95%CI: -0.053 to 0.098), and the limit of intra-observer agreement was 0.012 (95%CI: -0.034 to 0.059). A Sonosite Micromax ultrasound device paired with a 5-10 MHz multifrequency high-resolution linear transducer with Sonocal software was used for performing automatic measurements of IMT in order to optimize reproducibility. Measurements were made of the common carotid after the examination of a longitudinal section of 10 mm at a distance of 1 cm from the bifurcation, performing measurements in the anterior or proximal wall, and in the posterior or distal wall in the lateral, anterior and posterior projections - following an axis perpendicular to the artery to discriminate two lines: one corresponding to the intima-blood interface and the other to the media-adventitious interface. A total of 6 measurements were obtained of the right carotid and another 6 of the left carotid, using average values (average IMT) and maximum values (maximum IMT) calculated automatically by the software. The measurements were obtained with the subject lying down, with the head extended and slightly turned opposite to the exploratory side, following the recommendations of the Manheim Carotid Intima-Media Thickness Consensus . The aveThis was evaluated using the ankle-brachial index (ABI). The pressure in the extremities was measured using a portable Doppler system Minidop Es-100Vx  applying the probe at the anterior or posterior tibial artery at an angle of approximately 60° to the direction of blood flow. The ABI was calculated separately for each foot by dividing the greater of the two systolic pressures in the ankle by the greater of the two systolic pressures in the arm. TOD was considered if ABI < 0.9 .This parameter was estimated using the SphymgoCor System , with the patient in the supine position. The pulse waves of the carotid and femoral arteries were analyzed, estimating the delay with respect to the ECG wave and calculating the corresponding PWV. Distance measurements were taken with a measuring tape from the sternal notch to the carotid and femoral arteries at the sensor location. TOD was considered if PWV > 12 m/s .Kidney damage was assessed by measuring plasma creatinine concentration. Glomerular filtration rate (GFR) was estimated according to the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)  for CaucThe electrocardiographic examination was performed using a General Electric MAC 3.500 ECG System  that automatically measures the voltage and duration of waves and estimates the criteria of the Cornell voltage-duration product (Cornell VDP) . TOD wasInformation about kilocalorie intake was collected using the food frequency questionnaire of the University of Navarre, validated for Spain . In ordeContinuous variables are expressed as the mean ± standard deviation, and qualitative variables as frequency distributions. To analyze the changes in the different variables between the two assessments, use was made of the Student t-test for paired quantitative data, with application of the McNemar test for qualitative variables. The multivariate analysis involved a stepwise multiple linear regression model, using as dependent variables those resulting from the differences in evaluation of the target organ lesions between the two measures . After adjusting for age and sex, we included as independent variables in the analysis for each of the two groups those variables obtained from the differences between the two evaluations that reached statistical significance in the diabetes group  and in the metabolic syndrome group . In a second step using the stepwise method, only those variables which reached statistical significance in the regression model remained in the result of the analysis. The data were analyzed using the SPSS version 18.0 statistical package . A value of p < 0.05 was considered statistically significant.Throughout the year of study of follow-up, two males died as a result of acute myocardial infarction, one with T2DM and the other with metabolic syndrome .At the baseline evaluation, the diabetic patients were 4.5 years older on average (p = 0.03), with a greater percentage of past cardiovascular events, higher C-reactive protein, fibrinogen and HOMA values, and less favorable vascular, renal and cardiac damage indicators, presentando un mayor porcentaje de pacientes activos (45.60% vs 29.50%). In contrast, the subjects with metabolic syndrome showed a poorer lipid profile, and poorer obesity and blood pressure parameters, though for most of the analyzed variables the differences failed to reach statistical significance. Mean antihypertensive and lipid-lowering drug use was greater among the patients with T2DM. La ingesta calórica día fue similar en los dos grupos (2449.29 ± 726.42 vs 2477.08 ± 849.93)Evaluation after one year, the behavior of the risk factors was similar to that of the data commented above, with a tendency towards improvement of the obesity, lipid profile and blood pressure parameters in both groups. However, IMTCc was seen to equalize in both groups, PWV decreased, and the Cornell voltage-duration product increased in the patients with metabolic syndrome. Antihypertensive and lipid-lowering drug use increased in the subjects with metabolic syndrome Tables , 3 and 4On analyzing the differences in the risk factors, vascular, renal and cardiac TOD and antihypertensive and lipid-lowering drugs between baseline and the evaluation after one year, a significant decrease was noted in BMI and diastolic blood pressure, together with an increase in fibrinogen and ABI in the patients with T2DM. In contrast, the patients with an initial diagnosis of Metabolic syndrome showed a significant drop in systolic and diastolic blood pressure, HOMA index and PWV, and an increase in HDL-Cholesterol, serum glucose, fibrinogen, ABI, Cornell voltage-duration product and antihypertensive and lipid-lowering drug use Tables .2 = 0.235), and the difference in antihypertensive and lipid-lowering drug use in relation to the Cornell voltage-duration product (R2 = 0.258). However, in the diabetic patients and following the same regression analysis, the variable remaining in the model explaining the differences in PWV (R2 = 0.133) and Cornell voltage-duration product (R2 = 0.104) was seen to be the difference in systolic blood pressure  to the data obtained in Caucasians with T2DM in the metaanalysis published by Brohall et al. . The meaThe mean PWV values in the diabetics  were similar to those reported by Lacy et al. , and higThe behavior of ABI was similar in both patient groups, with an increase after one year of follow-up. Similar data have been published by Ito et al.  in patieThe evaluation of left ventricular hypertrophy based on the Cornell voltage-duration product did not vary between the two evaluation time points in the diabetic patients, though it was seen to increase at the second measurement in the patients with metabolic syndrome. Apart from the low sensitivity (31%) of electrocardiography in detecting left ventricular hypertrophy, the electrocardiographic criteria are of little diagnostic use in the isolated interpretation of a patient with left ventricular hypertrophy . In any 2 and greater than those recorded in other studies [There were no differences in glomerular filtration rate estimated with the CKD-EPI equation either between evaluation timepoints or between groups the values in all cases being over 85 ml/min/1.73 m studies ,37. LikeThis study has some limitations that must be considered when interpreting the results obtained. Firstly, the number of subjects per group, which limits the power of an analyses made, as well as follow-up limited to the first year of the study. It also should be taken into account that selection was not randomized but involved consecutive sampling, and the two groups are not fully balanced in terms of age (4 years of difference) - a fact that may influence the course, though the analyses have been adjusted for this variable in order to minimize its influence.The annual assessment of cardiovascular risk factors and the decrease in pulse wave velocity was more favorable in the patients with metabolic syndrome, probably influenced by the increased percentage of subjects treated with antihypertensive and lipid lowering drugs in this group.T2DM: Diabetes mellitus tipo 2; TOD: target organ damage; LVH: Left ventricular hypertrophy; IMT: Intima-media thickness; PWV: Pulse wave velocity; IMTCc: Intima-media thickness of the common carotid artery; ABI: Ankle-brachial index; PWV: Pulse wave velocity; SBP:Systolic blood pressure; DBP: Dyastolic blood pressure; PP: Pulse pressure; GFR: glomerular filtration rate; CKD-EPI: Chronic Kidney Disease Epidemiology Collaboration.The authors declare that they have no competing interests.MAGM devised the study, designed the protocol, participated in fund raising, interpretation of results, prepared the manuscript draft and corrected the final version of the manuscript. JIRR and CAC participated in the study design, data collection and manuscript review. MCPA performed all analytical methods, interpretation of results, and manuscript review. ERS, LGS and LGS participated in the study design, interpretation of results, and manuscript review. LGO participated in the protocol design, fund raising, analysis of results, and final review of the manuscript. Finally, all authors reviewed and approved the final version of the manuscript.


Cardiovascular disease (CVD) is highly prevalent in patients with chronic kidney disease (CKD). Inhibition of the renin-angiotensinsystem (RAS) in hypertension causes differential effects on central and brachial blood pressure (BP), which has been translated into improved outcome. The objective was to examine if a more complete inhibition of RAS by combining an angiotensin converting enzyme inhibitor (ACEI) and an angiotensin receptor antagonist (ARB) compared to monotherapy has an additive effect on central BP and pulse-wave velocity (PWV), which are known markers of CVD.2) participated in an open randomized study of 16 weeks of monotherapy with either enalapril or candesartan followed by 8 weeks of dual blockade aiming at a total dose of 16 mg candesartan and 20 mg enalapril o.d. Pulse-wave measurements were performed at week 0, 8, 16 and 24 by the SphygmoCor device.Sixty-seven CKD patients  and in augmentation index  compared to monotherapy. Furthermore pulse pressure amplification was improved (P<0.05) and central systolic BP reduced .Dual blockade of the RAS resulted in an additive BP independent reduction in pulse-wave reflection and arterial stiffness compared to monotherapy in CKD patients.Clinical trial.gov NCT00235287  Markers of arterial stiffness such as aortic pulse-wave velocity (PWV) and central blood pressure (BP) are known independent predictors of cardiovascular morbidity and mortality in chronic kidney disease (CKD) In the present study it was investigated for the first time whether in CKD patients dual RAS blockade has an additive effect on central pressure waves and arterial stiffness evaluated by pulse-wave analysis (PWA) and PWV respectively, compared to mono RAS blockade, and whether these effects if present are BP independent.The protocol for this trial and supporting CONSORT checklist are available as supporting information; see www.clinicaltrials.gov, registration number NCT00235287.Sixty-seven patients, all Caucasians, from the outpatient nephrology clinic, Herlev University Hospital, 52 men and 15 women, mean age 60 (range 31–75) were enrolled in this open randomised cross-over trial from September 2005 to September 2009. All patients gave informed consent and the study was approved by the Ethical Committee of Copenhagen County. The authors adhered to the Declaration of Helsinki and the study was monitored by the Good Clinical Practice (GCP) unit at Copenhagen University Hospitals, and was registered by EudraCT number 2005-001568-29 and in the public trial registry: The eligibility criteria for patients entering the study were pre-dialysis CKD with plasma creatinine between 150 and 350 µmol/l, plasma potassium below 5.6 mmol/l, systolic BP above 109 mmHg and age between 18 and 75 years. Patients with congestive heart failure (NYHA III-IV), chronic liver insufficiency, amputation of a limb or the presence of cardiac arrhythmia or a pacemaker were not included. None of the patients were to be treated with immunosuppressives, non-steroidal anti-inflammatory drugs, aldosterone antagonists or dual RAS blockade at the entry of the study.Seventy-two per cent of the patients were treated with ACEI or ARB before enrolment and thus were known RAS blockade tolerant. Additionally, most were treated with furosemide and non ACEI/ARB antihypertensive therapy, which were continued during the trial. Demographic data and renal diagnoses are shown in In order to ensure close balance of the numbers in each group at any time during the trial, block randomization was used Randomization of patients treated with either an ACEI or an ARB prior to the study was carried out by drawing a closed envelope; to ensure that half of the patients had enalapril for the first 16 weeks and the other half had candesartan the first 16 weeks.Randomization of patients not treated with an ACEI or ARB prior to the study was likewise carried out by drawing an envelope from a bag to ensure that half of the patients had enalapril in the first 8 weeks and candesartan in the following 8 weeks and the other half of the patients had candesartan in the first 8 weeks and enalapril in the following 8 weeks. By this means, tolerance to either drug was demonstrated in the patients not previously treated with RAS blockers before dual blockade.In either of the four randomized patient groups, doses were increased gradually over a period of 8 weeks from enalapril 5 mg to 20 mg, and from candesartan 4 mg to 16 mg, given once daily. All randomisations were carried out by the GCP-trained nurse staff members of the outpatient clinic without any conflict of interest in the trial. A flowchart of the randomized patients in the study is found in All patients: After 16 weeks of monotherapy with either enalapril or candesartan, the complementary drug was added in incremental doses over a period of 5 weeks, aiming at reaching a combination of enalapril 20 mg and candesartan 16 mg and maintaining this full dose dual blockade for an additionally 3 weeks. The therapeutic goal was a systolic/diastolic BP of 130/80 mmHg or below according to the K/DOQI-guidelines 51Cr-EDTA as described below. Urinary albumin excretion/24 h was measured at each of the four visits of pulse-wave measurements.During the 24 weeks study period, 10 control visits were planned: 4 visits in the laboratory, at which pulse-wave measurements were done and blood samples drawn, at the beginning of the trial and after 8, 16 and 24 weeks; 6 ‘clinical control’-visits in the outpatient clinic, at which BP was measured and blood samples drawn. All the visits were planned with an interval of 2–3 weeks throughout the study, so that 2 ‘clinical control’-visits were placed between two pulse-wave measurements. Glomerular filtration rate (GFR) was estimated at the first and last visit in the trial by the plasma clearance of Measurements of PWA and PWV were performed using the SphygmoCor© device The quality demands of PWA and PWV were followed as suggested by the manufacturer. This included visually acceptable pulse-wave recordings with variations in pulse height, diastole and pulse length ≤5% and the mean pulse height ≥80 mV as expressed by a quality index (%) provided by the software. A quality index ≥80% was accepted. In case of PWV, the time difference between the ECG-signal and the signal from the recording sites should have a SD ≤10% of the mean value. All measurements of PWA and PWV were made in duplicate.Management of hyperkalemia, excess rise in plasma creatinine and hypotension have been described in details elsewhere The brachial BP used for calibration of PWA and all other brachial BPs were measured by use of a mercury sphygmomanometer after at least 10 min of supine rest. The mean of the last two out of three BP measurements were averaged and used for analysis. Plasma creatinine was analyzed using reagents from Vitros Chemistry 5.1, which are compatible with the IDMS method (isotope dilution mass spectrometry). Plasma potassium and other clinical chemistry parameters were measured using standard methods.51Cr-EDTA Plasma clearance was calculated on the basis of plasma activity in four blood samples drawn at 20-min intervals in the fourth hour after injection AIx@HR75 defined as the difference between the first and second systolic peaks expressed as a percentage of the pulse pressure adjusted to a heart rate of 75 beats/min- was taken to represent measures of arterial wave reflection AIx@HR75, TR and PP-amplification.The pulse-wave is composed of an initial pulse-wave generated by left ventricular ejection and its reflection from the periphery. The sample size was calculated using a two-sided paired sample t-test based on variations from previous data The two groups with or without prior RAS-blockade were then randomized to four different treatment groups, which were compared for differences in demographic characteristics by analysis of variance. As no differences were found between groups demographic data are shown for all patients together. The effects of dual therapy and monotherapy on pulse-wave measurements were analyzed by general linear models for repeated measurements. As no differences were found between the four treatment arms data were pooled and further analyzed in total. We aimed to evaluate the effects of dual blockade on pulse-wave measurements and therefore based the statistical analysis on the 57 patients who completed dual blockade.AIx@HR75, aortic PWV and brachial PWV were adjusted for diastolic BP, gender and age. Furthermore AIx@HR75 was adjusted for body-height, aortic PWV, TR and ED in a similar way, like the PP-amplification ratio which was adjusted for heart rate and body-height. Data are presented as mean ± standard deviation (SD) unless otherwise stated. Due to skewed distribution urine albumin excretion and GFR were log-transformed before analysis and the geometrical mean presented with range in brackets. A P-value <0.05 was considered significant. Data were analyzed by use of a statistical computer program .The effects of treatment on kidney function were evaluated by use of Student’s t-test for dependent data. During the analyses of repeated measurements, Of the 67 randomized patients, 57 completed the trial. All pulse-wave measurements were within our quality standard as described in the methods section. The mean quality index was 95±6%.No differences were found between randomization groups in demographic data or baseline-values of pulse-wave measurements and clinical chemistry parameters. No differences were detected between treatment arms in the response of dual- versus mono-RAS blockade. These data are therefore presented as pooled data  and 2. TThe effects of mono- and dual RAS-blockade on pulse-wave measurements and on kidney function are presented in A significant additive reduction was observed in aortic PWV of 0.3 m/s after combined treatment compared to monotherapy corresponding to a difference of 3%. This was independent of diastolic BP, age and gender. No significant change was detected in brachial PWV . The heaAIx@HR75) decreased significantly during dual blockade versus monotherapy by 2% corresponding to a proportional difference of 11%. This was independent of diastolic BP, age, body-height and gender  and not related to changes in Time to reflection (TR), Ejection duration (ED) or aortic PWV. No additive change was seen in TR, heart rate or ED during dual-blockade. of the patients failed to tolerate full dual blockade with enalapril and candesartan, and had to be given lower doses of one or both of the drugs, or in 10 cases withdrawn from the study Transient hyperkalemia was frequently seen as previously described The main finding of this study is the BP independent reduction in arterial stiffness and pulse-wave reflection after combined treatment with enalapril and candesartan compared to monotherapy in patients with CKD. Furthermore pressure amplification was increased during dual blockade compared to monotherapy.Aortic PWV is considered a direct measure of arterial stiffness AIx@HR75) of 2% after dual blockade compared to a reduction during mono-blockade of 2% as well. Even after adjustment for known determinants of AIx as diastolic BP, height, gender and age AIx@HR75 was still significant. This reduction in AIx@HR75 was related to the change in brachial PWV even though this change did not achieve statistical significance. This indicates that the reduction in the intensity of wave-reflection was the principal mechanism of the change in AIx@HR75 caused by a dilatation of medium-sized muscular arteries and thereby a reduced brachial PWV. This relationship has been emphasized by others Pulse-waves are in most studies analyzed by three parameters: central PP, central systolic BP and AIx Dual blockade significantly reduced brachial and central systolic BP on average by 7 and 6 mmHg respectively on top of a decrease during monotherapy of 11 and 12 mmHg respectively. A significant increase in PP-amplification was seen , indicatNo previous studies have been conducted on the effects of dual blockade on pulse-wave measurements in CKD patients. A study of 18 hypertensive patients with normal renal function treated with ACEI showed that add on valsartan reduced central BP more than brachial BP. A significant reduction in AIx of 13% was found after 2 weeks Our patients had moderate to advanced CKD (stage 3–5) where inhibition of RAS can be a challenge due to loss of kidney function AIx@HR75 was independent of BP suggests that the decrease in arterial stiffness was caused by the direct effect of the drug on the vascular wall. The common feature of ACEI and ARB appears to be their dilating capacity on especially peripheral muscular arteries and their ability to reduce wave-reflections, as expressed by AIx Reduction of BP is known to reduce arterial stiffness The cross-over design allowed for comparisons within the same patient. It would, however have been valuable with a control group treated with ACEI/ARB monotherapy parallel to the dual treatment period to rule out the time factor as a confounder. The period of dual blockade was deliberately not randomized, because of the crucial need for a cautious dose titration in each mono-therapy before start of dual blockade in these vulnerable patients, which necessitated the placement of the dual blockade treatment period in the end of the trial.There was no statistical difference between randomization arms, which allowed for analysis of data pooled together. We cannot though, exclude the possibility that inter-group differences did exist, but were not found due to small numbers in each randomization group. However, we consider, that by pooling data more powerful results were achieved.AIx@HR75 compared to mono-therapy. Likewise, central systolic BP was reduced and PP-amplification was increased during dualblockade. As these are all independent predictors of cardiovascular mortality in CKD patients, the beneficial effects of dual RAS blockade found in this study might lead to a favorable effect on cardiovascular outcomes in CKD patients beyond that achieved by monotherapy.In CKD patients, combined RAS blockade with enalapril and candesartan caused additive significant BP independent reductions in aortic PWV and Protocol S1Trial Protocol.(DOCX)Click here for additional data file.Checklist S1CONSORT Checklist.(DOC)Click here for additional data file.


Standard clinical practice in patients with elevated intracranial pressure (ICP) is to keep cerebral perfusion pressure (CPP) at (or above) 60 mmHg: we performed this retrospective study to analyze whether induction of barbiturate coma impedes compliance to this target CPP value. It has been repetitively shown that, although proven as an efficient therapy for refractory elevated ICP, barbiturate coma may cause a decrease in mean arterial pressure (MAP) and CPP .All patients that had received sodium thiopental in our ICU during 2011 were identified and their medical and nursing records were retrospectively analyzed. The effect of administration of sodium thiopental  on MAP, ICP and CPP was evaluated. Values are reported as mean ± SD. The changes over time in ICP, MAP and CPP are reported as means with their 95% CI.In 2011, a total of 20 patients were treated in our ICU with barbiturate coma for refractory elevated ICP. In five patients, systemic hypothermia was simultaneously induced. These patients were excluded from further analysis. Six patients died during their stay in the ICU and nine patients could be discharged to the neurosurgical ward. The mean peak ICP value before induction of barbiturate coma was 26 ± 3 mmHg, and the ICP value 6 hours later was 20 ± 6 mmHg. The MAP at those same time points was 91 ± 12 mmHg and 81 ± 11 mmHg, respectively. The CPP, calculated from both previous values, was 66 ± 13 mmHg and 61 ± 11 mmHg, respectively. At both time points, the dose of noradrenaline was comparable . Analysis of the change in ICP, MAP and CPP over the 6-hour period showed a significant decrease in ICP of -5.8 mmHg  . The MAP significantly decreased by -10.4 mmHg . The decrease in CPP was not significant ).This retrospective study indicates that inducing a thiopental coma in patients with refractory elevated ICP effectively reduces ICP. Although the concomitant reduction in MAP was significant, the resulting decrease in CPP was small and nonsignificant. Moreover, the target CPP of 60 mmHg was maintained after induction of barbiturate coma.


Glycine allele at codon 16 has previously been associated with the increase in asthma severity, bronchial hyperresponsiveness and also the increase in inhaled corticosteroid dependence. This study was designed to evaluate the genetic alleles in mild asthma. 1 ≥ 80%, positive methacholine test) and body mass index (BMI ≤ 30 Kg/m2) were included in the study. They could only use short acting beta-2 agonists for asthma control. Smoking, infection, occupational sensitizers’ exposure, gastroesophageal reflux, diabetes mellitus and heart failure were also considered as exclusion criteria. All patients were genotyped at 16th and 27th codons. Thirty-four patients with diagnosis of mild asthma  Arg/Gly, 14 (41.2%) Arg/Arg and no Gly/Gly genotype were detected at codon 16. Genotyping at codon 27 revealed 2 (5.9%) Glu/Glu, 13 (38.2%) Glu/Gln and 18 Gln/Gln (52.9%). Based on the obtained results, Arg/Gly mutation had a higher rate among the studied subjects compared to Arg/Arg polymorphism. This is a pilot study which shows a probable usefulness of genotyping for predicting of asthma severity.  Asthma is a chronic polygenic disease. The total cost per patient is estimated around 1,000 Euros yearly for patients with mild persistent asthma  who referred to the pulmonary clinic of Masih Daneshvari Hospital with the following inclusion criteria were entered into the study.Patients with diagnosis of mild asthma (FEV2), smoking or infections within one month prior to the study procedure or exposure to occupational sensitizers were excluded from the study. In addition, those who took medications which causes cough or exacerbate asthma condition, i.e. angiotensin converting enzyme inhibitors (ACEIs), nonsteroidal anti-inflammatory drugs (NSAIDs) and β-blockers, were not included in the study either. They could only use short acting beta2 agonists for asthma control.Cases with a history of gastroesophageal reflux, diabetes mellitus, heart failure, chronic obstructive pulmonary disease COPD, Churg-Strauss syndrome, bronchitis obesity , 50 mM KCl, 1.5 mM MgCl2, 1.5 U of Taq polymerase, 0.2 mM of each deoxynucleotide triphosphate and 30 pm of each primer. Temperature cycling was 94°C for 60 s, 60°C for 60 s and 72°C for 60 sec for 44 cycles and then a final extension for 7 min at 72°C. The size of generated PCR product was 168 bp , 2 μL PCR water, 2 μL of 50 mM NaCl, 10 mM Tris-HCl, 10 mM MgCl2 and 1 mM dithiothreitol (pH 7.9) at 37°C for 12 h. Nco. cuts 22 bp from the 3’-end of both alleles and 18 bp from the 5’- end of the Gly-16 allele. The restriction digests were electrophoresed on 3% agarose gels and visualized with ethidium bromide staining and gel documentation. The Gln27Glu polymorphism was identified in the second restriction digest using another aliquot of the same PCR product. Twelve μL of PCR product was digested with 2 U of Bbv. (New England Biolabs), 5 μL PCR water, in 2 μL of 50 mM NaCl, 10 mM of Tris-HCl, 10 mM of MgCl2 and 1 mM of dithiothreitol (pH = 7.9) at 37°C for 12 h. Bbv digests the Gln-27 allele to produce 105 and 63-bp fragments which are separated from uncut Glu-27 alleles on 3% agarose gels  Arg/Gly, 14 (41.2%) Arg/Arg, and no Gly/Gly genotypes were detected at codon 16. Genotyping at codon 27 revealed 2 (5.9%) Glu/Glu, 13 (38.2%) Glu/Gln, and 18 Gln/Gln (52.9%). Frequency of Arg and Glu allele were estimated 70.6% and 25.75% respectively. Data of patients’ haplotypes in the study is shown in B2AR (beta-2 adrenergic receptor) polymorphism has been studied and discussed by several studies in terms of asthma susceptibility, severity and responsiveness , 22-25.et al. study  was dominant compared to the frequency of Gly allele (29.4%). This finding is consistent with results of Liggette l. study . The lowcurrence . In Ligg (et al. . The stuseverity . Though,et al. could not find any association between 27Glu/Gln or Arg/Gln polymorphism and asthma (Ramsey d asthma .et al. which evaluated the polymorphisms at codones 16, 27, and 164 in 86 patients, B2AR polymorphism was not recognized a causative strong factor for asthma exacerbation. No significant difference between Gly allele frequencies was detected between patients with mild and moderate asthma. Gly16/Glu27 haplotype was more prevalent in mild asthmatic patients (On the other hand, in a study by Weir etc (In general, it is clear that various host and environmental factors other than polymorphism can affect the severity of asthma; factors such as poor economic condition, lower level of education, concomitant diseases such as diabetes, heart failure, etc . For exaetc . But theThis study had some limitations as well. Owing to the extensively limited inclusion criteria, we were not able to enroll more patients in the study. So, small sample size limits the power of the study to represent this data as a perfect model of Iranian asthmatic patients. Studies with a bigger sample size should be conducted to give more reliable data for general population of Iranian patients. As a first time population study, it would be better to include a group of non-asthmatic patients as control group. However, this was the first study in this realm conducted on asthmatic patients in Iran and paved the way for further investigations on such patients.