Delirium is common in hip fracture patients and many risk factors have been identified. Controversy exists regarding the possible impact of intraoperative control of blood pressure upon acute (delirium) and long term (dementia) cognitive decline. We explored possible associations between perioperative hemodynamic changes, use of vasopressor drugs, risk of delirium and risk of new-onset dementia.Prospective follow-up study of 696 hip fracture patients, assessed for delirium pre- and postoperatively, using the Confusion Assessment Method. Pre-fracture cognitive function was assessed using the Informant Questionnaire of Cognitive Decline in the Elderly and by consensus diagnosis. The presence of new-onset dementia was determined at follow-up evaluation at six or twelve months after surgery. Blood pressure was recorded at admission, perioperatively and postoperatively.Preoperative delirium was present in 149 of 536 (28%) assessable patients, and 124 of 387 (32%) developed delirium postoperatively (incident delirium). The following risk factors for incident delirium in patients without pre-fracture cognitive impairment were identified: low body mass index, low level of functioning, severity of physical illness, and receipt of ≥ 2 blood transfusions. New-onset dementia was diagnosed at follow-up in 26 of 213 (12%) patients, associated with severity of physical illness, delirium, receipt of vasopressor drugs perioperatively and high mean arterial pressure postoperatively.Risk factors for incident delirium seem to differ according to pre-fracture cognitive status. The use of vasopressors during surgery and/or postoperative hypertension is associated with new-onset dementia after hip fracture. A hip fracture is a potentially devastating event, and serious surgical and medical complications occur frequently . One-yeaDelirium, characterised by an acute disturbance in awareness, attention and cognitive function  is one oSeveral established risk factors are identified for preoperative and postoperative delirium, including age, comorbidities and pre-fracture dementia . There iThere are some data suggesting that use of vasopressors (in particular phenylephrine) is associated with lower cerebral oxygen saturation  which inThe main objective of this study was to study risk factors for preoperative delirium, for incident delirium, and for new-onset dementia in the months after surgery in hip fracture patients, with emphasis on perioperative hemodynamic changes, and use of vasopressor drugs.This is a prospective follow-up study of two cohorts of hip fracture patients admitted to Ullevål University Hospital or Diakonhjemmet Hospital in Oslo, Norway. Cohort 1 was recruited from September 2005 through December 2006, and Cohort 2 from September 2009 through January 2012. This is an analysis of merged data from these cohorts. The methods of the individual studies have previously been described .Patients acutely admitted with a hip fracture  were eligible for inclusion. Patients were excluded if the hip fracture resulted from high-energy trauma or if they were considered as moribund by the orthopaedic surgeon at admission. Patients from nursing homes and patients with dementia were not excluded. Cohort 1 excluded patients < 65 years and patients with a length of hospital stay of < 48 hours.Demographic and social information, medical diagnoses, drug use, and information regarding anaesthetic and surgical procedures and complications were collected from medical and anaesthesiologic records, proxy interviews and questionnaires, patient interviews, and information from staff. Proxies provided information regarding pre-fracture cognitive function, using the short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE-SF)   preoperaAn experienced geriatrician (TBW) and an experienced specialist in old age psychiatry (KE) independently assessed whether a patient fulfilled the criteria for dementia, at baseline and at follow-up. In case of disagreement, a consensus diagnosis was made. They applied the International Classification of Diseases, version 10 (ICD-10) research criteria for dementia,  and usedVital signs, including non-invasive blood pressure, were recorded during anaesthesia according to hospital routines. Intraoperative blood pressure management was left to the discretion of the caring anaesthesiologist. Data was extracted from the perioperative anaesthesia chart (both electronic and paper records), and the lowest documented blood pressure during anaesthesia was used for analyses. Artifacts were excluded based on a clinical judgement. Preoperative measurements were recorded at admission, and postoperative measurements were recorded once 4 hours after surgery. Mean arterial pressure (MAP) was calculated as [(SBP + (2 x DBP))/3). Blood pressure was analysed as a continuous variable, but relevant thresholds were also explored: a MAP < 60 mm Hg, a MAP < 50 mm Hg, a MAP decrease > 30% and a MAP decrease > 40% relative to admission MAP.The researchers doing the follow-up visits were blinded to all clinical data including delirium status during the acute hospital stay. The follow-up visits included comprehensive cognitive testing, and an interview with proxies regarding cognitive and physical (ADL) function, using the same questionnaires as during the hospital stay. In Cohort 1, follow-up visits were performed by one researcher. In Cohort 2 they were done by one of two research nurses.The sample size was driven by convenience. We performed three sets of analyses: one for preoperative delirium, one for incident delirium and one for new-onset dementia at follow-up. Potential risk factors were selected based on literature and expert opinion. As dementia is a strong risk factor for delirium, we stratified the analyses for incident delirium according to pre-fracture cognitive status, to see if potential risk factors differed between the two strata. We used Student’s t-tests  or Mann-Whitney U-tests (skewed data) to compare continuous variables. Categorical variables were analysed using Chi-square tests.Variables with p-values ≤ 0.10 in univariate analyses were chosen for the multivariate logistic regression models. We followed a stepwise procedure for variable selection. First, models for background data, admission data and perioperative data, respectively, were developed. We decided to explore the potential risk factors in each of these categories separately in the intermediate models, and then to merge the significant variables  from each of these categories in the final multivariate model. Both forward and backward stepping procedures for variable selection were used, though they yielded the same models. Continuous variables were categorised into quartiles or quintiles to check for linearity. If their relationship to the outcome was not homogenous through their entire range, they were recoded into ordinal variables (cutpoints based on quartiles or quintiles) or dichotomised as appropriate based on the preliminary analyses. We assessed for confounders, and investigated multicollinearity using a correlation matrix and by exploring the variance inflation factor (VIF). If there was correlation above 0.6, one of the variables was omitted. Statistical analyses were performed using SPSS Statistics version 21 .Ethical approval for this study was provided by the Regional Committee for Ethics in Medical Research in Norway. Cohort 1 (REK s-05075) was approved on 18 April 2005  and Cohort 2 (REK S-09169a) on 25 March 2009 (Chairperson Prof. G. Nicolaysen). Both trials were also approved by the Data Protection Authorities and undertaken in accordance with the Declaration of Helsinki. Patients were enrolled based either on written consent or on presumed consent in combination with written assent from the nearest relative.In all, 696 patients were included in the study, 364 from Cohort 1 and 332 from Cohort 2 . Of the 2, were in higher ASA groups and had a longer waiting time from admission to surgery than those without delirium.Patients with preoperative delirium were significantly older and more functionally impaired, more often had preoperative cognitive impairment, were more often living in an institution and were more likely to have fallen indoors . They prPreoperative delirium data are missing for 127 patients in cohort 1 and 33 patients in cohort 2 . The rea2, to be in ASA group III or higher, or to receive ≥ 2 blood transfusions. In the final multivariate model, having a BMI of < 20 kg/m2, having an NEADL score of < 45 points, being in ASA group ≥ 3, and receiving ≥ 2 blood transfusions were found to be independently associated with incident delirium.Of the 387 patients who were free from delirium preoperatively, 124 (32%) developed delirium after surgery (incident delirium). In 29 of the 387 patients, an ICQODE score was missing. They were excluded from further analyses . Among pIn patients with a preoperative IQCODE score of ≥ 3.44 (i.e. cognitive impairment), those who developed incident delirium more often received benzodiazepine perioperatively .No significant associations were found between incident delirium and perioperative haemodynamic variables, type or duration of anaesthesia, or the administration of a vasopressor, neither in those with nor without preoperative cognitive impairment.Of all the patients, 273 were free from pre-fracture dementia, of which 213 were assessed at six (n = 106) or 12 (n = 107) months postoperatively, and 26 (12%) were diagnosed with incident dementia . In univIn the final multivariate model, being more than 82 years old, being in ASA group ≥ 3, having received a vasopressor during surgery, having higher MAP postoperatively and having suffered from delirium during hospital stay were found to be independently associated with new-onset dementia at follow-up.The diagnosis of hypertension was forced into the models for both incident delirium and new onset dementia, to account for the possibility that chronic hypertension may affect the consequence of transient hypotension; this did not modify the results. Sensitivity analyses using continuous variables did not change the final models significantly.In Cohort 1, 92 patients were lost to follow up . These pThe three main findings in this study of hip fracture patients are:First, postoperative hypertension and the use of vasopressors during surgery are both significantly associated with new-onset dementia at follow-up.Hypertension is a well-known risk factor for cognitive impairment and dementia . PatientIt could also be that patients with a subclinical neurodegenerative disease have a dysregulation of blood pressure, making them more prone to perioperative hypotension . The ind2) might be associated with poor postoperative cognitive outcomes [2), even when MAP increases [2 than otherwise healthy younger patients. Our finding needs to be confirmed in future studies, as this retrospective study was not primarily designed for exploring this relationship.The association between perioperative use of adrenergic agonists and new-onset dementia was statistically significant, even after adjusting for perioperative decrease in MAP, suggesting that the use of vasopressors might not only indicate relative or absolute hypotension. The same trend was present, although not statistically significant, among patients free from pre-fracture cognitive impairment who developed delirium postoperatively. A causative role of vasopressor use on new onset dementia is absolutely unclear and maybe unlikely. However, this finding is biologically interesting. Low cerebral tissue oxygen saturation  .In the gThird, we found no association between perioperative haemodynamic variables and incident delirium.One hypothesis in delirium pathophysiology is that intraoperative hypotension, leading to inadequate cerebral perfusion, increases the risk of postoperative delirium ,44,45. HStrengths of this study are that it comprises two fairly large and similar cohorts of hip fracture patients, including nursing home residents and persons with pre-existing dementia, who otherwise often are excluded. The cognitive assessments, including the dementia evaluations and bedside delirium diagnostics, were conducted using validated and robust methods. Follow-up allowed us to study long term cognitive outcomes.There are limitations that should be addressed. Although all patients in the current study were included in studies with prospective design, the measurements of perioperative hemodynamic variables were not standardised between the two studies, and some hemodynamic data had therefore to be collected retrospectively. We only registered one blood pressure and heart rate measurement pre- and postoperatively. We did not register the highest blood pressure values peroperatively or the duration of hypotensive episodes. We did not have data related to possible ICU admissions during follow-up. The sample size was driven by convenience. Even if the cohort is large and representative for hip fracture patients admitted to our hospitals, the number of patients with new-onset dementia is small, reducing statistical power for analyses of new-onset dementia and leaving the confidence intervals wide. The sample size was not large enough to include all the candidate variables into the model, and we had to follow a stepwise procedure. Unfortunately, the data are insufficient to properly assess the role of death as a competing risk in our model of new onset dementia, and there were patients lost to follow-up. Another weakness is that there was no delirium assessments on weekends, and that preoperative delirium data are missing for 160 patients. Neither delirium sub-types nor the specific timing of delirium episodes were explored. Time to follow-up was different in the two cohorts. If all patients had been assessed for new-onset dementia at 12 months, the sensitivity of our findings would have been higher.In hip fracture patients, delirium, the use of vasopressors during surgery and/or postoperative hypertension is associated with new-onset dementia after the fracture. The possible negative impact of vasopressors on clinical outcomes should be further explored in prospective studies. Risk factors for incident delirium seem to differ according to pre-fracture cognitive status. Low BMI, severity of physical illness, low extended ADL functioning and great blood loss seem to be risk factors for incident delirium in patients without pre-fracture cognitive impairment.


T1rest, T1stress, and T1 reactivity in patients referred for regadenoson perfusion CMR were not significantly different when comparing patients with <4 h coffee intake and patients who reported no coffee intake  , and similar to values in patients without coffee intake undergoing adenosine CMR. In patients with <4 h coffee intake, T1stress, and T1 reactivity were significantly lower for adenosine  compared to regadenoson perfusion CMR (p < 0.001). Coffee intake <4 h prior to regadenoson perfusion CMR has no effect on stress-induced hyperemia as measured with T1 mapping.The antagonistic effects of caffeine on adenosine receptors are a possible cause of false-negative stress perfusion imaging. The purpose of this study was to determine the effects of coffee intake <4 h prior to stress perfusion cardiac magnetic resonance imaging (CMR) in regadenoson- versus adenosine-induced hyperemia as measured with T1-mapping. 98 consecutive patients with suspected coronary artery disease referred for either adenosine or regadenoson perfusion CMR were included in this analysis. Twenty-four patients reported coffee consumption <4 h before CMR ; 74 patients reported no coffee intake . T1 mapping was performed using a modified look-locker inversion recovery sequence. T1 reactivity was determined by subtracting T1 The eceptors , 4. Anot disease –7. A par disease . They ar disease , 10, and disease . Caffein2A agonistic properties of regadenoson.In CMR, native (non-contrast) T1 mapping can be used for the quantification of myocardial water content, as a derivative measure of myocardial blood volume (MBV) . This prThe purpose of this study was to determine the effects of coffee intake less the 4 h prior to stress perfusion CMR in regadenoson- versus adenosine-induced hyperemia.The institutional review board approved this study. All patients provided written informed consent before enrolment. Between August 2015 and March 2016, 260 consecutive patients with suspected coronary artery disease referred for stress CMR with either adenosine or, in case of contra-indications to adenosine , regadenoson were screened. All patients received prior, routine instructions, sent to their home, to avoid potential adenosine or regadenoson agonists for at least 24 h before CMR . In addition, all anti-anginal medication (including beta-blockers) was discontinued 4 days prior to the examination. Patients on dypiridamole and unable to discontinue this drug were excluded. At arrival in the MRI facility patients were systematically interviewed on the recent intake of coffee and other caffeine containing substances. Visual assessment of the first pass perfusion images, motion artefacts, and Late Gadolinium enhancement images was performed. Patients were excluded from further analysis when ischemia, infarction, substantial motion artefacts, or technical failures were present A flow chart of the inclusion/exclusion is shown in Fig. A 1.5T MRI system  was used in all patients. After the standard cine images, an investigational modified look-locker inversion recovery (MOLLI) based T1 mapping sequence (WIP780B) was performed at rest and in stress. A 53)3 sampling scheme of the heart was performed, including 8 images in 11 heartbeats. For the MOLLI acquisition an initial Inversion time of 110 ms was used with an 80 ms increment. A pixel-wise T1 map of the myocardium was acquired in a mid-ventricular short-axis view with inline motion correction. The images were generated using a single-shot steady-state free-precession readout. Typical parameters were: field of view, 300 × 256 mm²; slice thickness 8 mm; base resolution 192; in plane spatial resolution, 1.4 × 1.4 mm²; bandwidth, 1085 Hz/pixel; flip angle, 35° and parallel imaging acceleration factor, 2. Native T1 maps were acquired at rest, and 60 s after intravenous regadenoson injection . Next, stress-only perfusion imaging was performed as previously described . In brie3 samplinT1 maps were independently analysed by two radiologists  with more than 10 years of experience in CMR. Both readers performed the analysis in a random order and were blinded to the patient data. The quantitative measurements of the T1 relaxation times were performed using commercially available mapping software . To avoid partial volume effects of the blood pool, all samples were in the core of the ROI, using conservative septal sampling . For thit test, and paired t test in case of paired data. One-way ANOVA was used to compare three or more groups. Statistical significance was defined as a p-value < 0.05. Statistical analyses were performed by using SPSS statistics 23 .Continuous values are presented as mean values with ±standard deviation (SD). Categorical data are presented as percentages. Differences between two groups were assessed by using independent sample The total study population consisted of 98 consecutive patients, aged 65 ± 11 years, with 49% men. 24 patients reported consuming coffee <4 h  before stress perfusion CMR and 74 patients who reported no coffee intake . Patient characteristics and hemodynamics are shown in Table rest, T1stress, and T1 reactivity values are shown in Table rest, T1stress, and T1 reactivity were not significantly different when comparing the control adenosine group with the control regadenoson group .T1rest in adenosine perfusion CMR was not significantly different when comparing patients with coffee intake <4 h prior to the examination with patients who reported no coffee intake (at p = 0.83). In contrast, T1stress, and T1 reactivity in patients with <4 h coffee intake were significantly lower as compared to patients without self-reported coffee intake (both at p < 0.001).T1rest, T1stress, and T1 reactivity in patients undergoing regadenoson perfusion CMR were similar for patients with coffee intake <4 h prior to the examination and patients who reported no coffee intake .T1rest in patients with self-reported coffee intake was similar for patients undergoing adenosine perfusion CMR and patients undergoing regadenoson perfusion CMR at p = 0.96. However, T1stress, and T1 reactivity were significantly lower in patients with <4 h coffee intake undergoing adenosine perfusion CMR when compared to patients with self-reported coffee intake undergoing regadenoson perfusion CMR both at p < 0.001.T1rest) was not significantly different when comparing adenosine perfusion CMR with regadenoson perfusion CMR (at p = 0.18). HR during stress (HRstress) was significantly lower in the control group of patients undergoing adenosine perfusion CMR as compared to the control group with regadenoson perfusion CMR (at p < 0.001). There was no significant difference in the diastolic blood pressure (RR) response when comparing the adenosine control group with the regadenoson control group (at p = 0.37). The systolic RR response and Heart rate response (HRR) were significantly lower in the adenosine control group as compared to the regadenoson control group .In the group of patients who reported no coffee intake (controls), resting heart rate . In the patients undergoing regadenoson perfusion CMR both HRrest and HRstress were significantly higher in patients without self-reported coffee intake when compared to the patients with coffee intake <4 h prior to the examination . The diastolic RR response, systolic RR response, and HRR in control patients undergoing adenosine perfusion CMR were not significantly different when compared to the diastolic and systolic RR response in patients with <4 h coffee intake at p = 0.96, 0.96, and 0.95. The diastolic RR response, systolic RR response, and HRR in patients without self-reported coffee intake undergoing regadenoson perfusion CMR were also not significantly different when compared to the diastolic and systolic RR response in patients with <4 h coffee intake at p = 0.81, 0.69, and 0.299, respectively.There was no significant difference in HRstress and the T1 reactivity are not significantly affected by consumption of coffee in the hours prior to the stress perfusion CMR when regadenoson is used as stressor, in contrast to adenosine where coffee intake causes a strong negative effect. In the patients without coffee intake both stress agents induced a comparable increase in MBV as measured with T1 mapping and the ΔT1 values in these groups showed no significant difference with ΔT1 of the regadenoson caffeine <4 h group.Our study is the first to perform a direct comparison comparison of the effects of coffee intake prior to either adenosine or regadenoson stress perfusion CMR. To assess changes in myocardial blood volume, we determined native T1 values and we report that T1Previous research on the effects of caffeine ingestion on the response to vasodilator agents in stress perfusion imaging is limited and the available evidence shows contradictory results.A study by Gaemperli et al. showed that, in positron emission tomography (PET) imaging, ingestion of a 200 mg caffeine capsule 2 h prior to regadenoson stress perfusion imaging had no significant effect on the pharmacological response as measured by the increase in myocardial blood flow during stress . However2A nature of regadenoson as compared to adenosine. Regadenoson already achieves maximal coronary hyperemia when only 25% of the A2A receptors is occupied [2A agonist and thus potentially more sensitive to the competitive antagonistic properties of caffeine.A possible explanation for our findings is the selective and potent Aoccupied . AdenosiSecondly, a relatively high dose of caffeine  was used in the regadenoson MPS study 90 min prior to the examination . In our rest and HRstress were significantly lower in the group with coffee intake prior to the examination. These results are in conjunction with a study by Bitar et al., who reported a blunted rise in heart rate but no significant difference in HRR when comparing patients with and without caffeine ingestion [Animal studies investigating the effects of increasing concentrations of caffeine have shown a dose dependent relationship between caffeine and hemodynamic effects such as lowering of heart rate in the first hours after caffeine ingestion , 21. In ngestion . The heangestion .In our study the diastolic RR, systolic RR and HRR response in the patients undergoing regadenoson perfusion CMR were not significantly different when comparing patients with and without self-reported coffee intake. The differences in the hemodynamic response to either adenosine or regadenoson in combination with caffeine intake is possibly explained by interaction of the substances leading to a combination of altered sympathetic tone, variable chemoreceptor response, and vasodilatory effects .This study was performed in a small study population with only self-reported coffee intake, meant as a proof of concept. Serum caffeine measurements were not performed and patients did not received a fixed dose of caffeine. We cannot exclude the possibility that a number of patients in our study has consumed other caffeine containing substances in the period before the examination. If so, this would have led to bias towards zero in the adenosine group, meaning that the measured effect that we found in our study is possibly an underestimation of the real effect of caffeine intake on hyperemia in adenosine perfusion CMR. Another limitation is the selection bias because only patients with contra-indications to adenosine, in this study COPD, received regadenoson as stressor. Due to the inability of these patients to perform an adequate breath hold, the MOLLI sequence used in this study showed many studies with motion artefacts, which could have been overcome by using shorter independent heart rate T1 sequences.Our study is the first to report on the effects of coffee intake prior to regadenoson perfusion CMR. We show that, in contrast to the negative effects during adenosine perfusion CMR, coffee intake has no effect on the hyperaemic response to regadenoson, as indicated by the T1 reactivity mapping.This finding may be important in clinical practice, because regadenoson can be used directly as an adequate alternative stressor in patients referred for adenosine stress CMR who inadvertently ingested coffee before the stress study, reducing the number of cancelled and rescheduled stress studies.Furthermore T1 reactivity, as an imaging biomarker, can be used as a bench-mark for the assessment of stress adequacy during vasodilator perfusion CMR and should be reported in the results.Coffee intake <4 h prior to regadenoson perfusion CMR appears to have no effect on stress induced hyperemia as measured with T1 mapping.


Multiple ordinal regression analysis showed that anemia  and AHI  were independently associated with Rutherford grade. Our study shows that AHI, a novel parameter based on the ABI measurement, is well correlated with ischemic symptoms, and may be a useful means to assess the arterial blood supply of the lower extremities of patients with PAD.In peripheral arterial disease (PAD) of the lower extremities, the presence of flow-limiting stenoses can be objectively detected by the ankle-brachial index (ABI). However, the severity of ischemic symptoms is not necessarily associated with the ABI value. Atherosclerotic plaque in lower extremity PAD induces ankle arterial stiffness and reduces ankle vascular resistance, which may decrease ankle blood flow and cause ischemic symptoms. We hypothesized that the ankle hemodynamic index (AHI), defined as the ratio of ankle arterial stiffness to ankle vascular resistance, could be used to assess the blood supply deficiency in a diseased lower limb in patients with PAD. The 85 consecutive patients with PAD who were retrospectively analyzed in this study had Rutherford grade 1 to grade 6 ischemia diagnosed as PAD and significant stenotic lesions (>50% diameter stenosis) of the lower extremity on contrast angiography. The AHI was calculated as the product of the ankle pulse pressure and the ratio of heart rate to ankle mean arterial pressure . The Rutherford grade was significantly correlated with the AHI ( Peripheral arterial disease (PAD) is a significant public health concern; worldwide more than 202 million adults have been diagnosed with the disease. Moreover, it poses a significant economic burden, reflecting the treatment of advanced disease, the alleviation of symptoms, and the prevention and treatment of ischemic events , 2. PAD The presence of flow-limiting stenoses can also be objectively and noninvasively detected using the ankle-brachial index (ABI), defined as the ratio of systolic blood pressures in the ankle artery to those in the brachial artery, to assess the hemodynamics of the lower limbs . In factBlood flow to the lower extremities or ankles reflects the difference between arterial and venous pressures (perfusion pressure gradient) and the conductance of the vascular tree . In patiWe hypothesized that the AHI, an easily obtainable and novel parameter based on ABI measurements, may be correlated and associated with ischemic symptoms in patients with PAD, and could be used to objectively and noninvasively assess deficient blood supply in diseased limbs. The purpose of this study was to investigate the correlation compared with ABI and the association between AHI and the severity of lower limb ischemia, classified by the Rutherford grade. Thus, we aimed to: 1) evaluate the correlation between the AHI, ABI, and the Rutherford grade, and 2) to determine the independent variables associated with the Rutherford grade using AHI and other clinical variables such as patients’ characteristics and objective clinical variables.The clinical investigation was conducted according to the principles stated in the Declaration of Helsinki. The study protocol was approved by the Institutional Review Board of Saitama Medical University International Medical Center. Written informed consent for the examination, including angiography, was obtained from all patients.The 115 patients consecutively enrolled in this study between May 2011 and February 2015 were evaluated for Rutherford classification grades 1–6)  6, 7] b b7] by t b b7] by™; Fukuda Dehnshi Co., Ltd., Tokyo, Japan). ABI and AHI were calculated based on bilateral brachial systolic blood pressure (SBP), bilateral ankle SBP, ankle diastolic blood pressure (DBP), ankle PP, ankle MAP, and heart rate, which were measured simultaneously during ABI determination. ABI was defined as the ankle SBP of the diseased limb/the highest SBP of that measured in each arm [Before the contrast angiography examination, patients were evaluated for ABI and AHI after resting for 5 min in the supine position. Measurements were made using a previously validated , 16 autoeach arm , 17, andBaseline patient data, including age, sex, height, weight, and body mass index (BMI), were recorded. Hypertension was defined as current or previous treatment with antihypertensive medication, diabetes as current or previous treatment with antidiabetic medication , and dyslipidemia as current or previous treatment with antidyslipidemic medication. A history of either end-stage renal disease requiring hemodialysis or collagen disease  was recorded based on interviews with the patients and/or their relatives. Medications including aspirin, clopidogrel, cilostazol, warfarin, statins, and angiotensin-converting enzyme (ACE) inhibitors at the time of ABI measurement were also recorded. Laboratory data consisted of hemoglobin, creatinine, and C-reactive protein (CRP) levels, activated partial thromboplastin time (APTT), prothrombin time-international normalized ratio (PT-INR), and albumin. Left ventricular ejection fraction, measured by transthoracic echocardiography, was also recorded.P value <0.05 in the univariate analyses were included in the multivariate analyses; collinearity was verified for each pair of variables. Because higher brachial SBP, heart rate, ankle PP, and ankle MAP were components of both the AHI and the ABI, they were excluded from the multiple ordinal logistic regression model to allow multiple collinearities to be taken into account. A P value of <0.05 was considered to indicate statistical significance for all analyses.All statistical analyses were performed using SPSS statistical software . Continuous variables are expressed as the mean±standard deviation or median (first to third quartile), and categorical variables as numbers and percentages. The normality of continuous variables was assessed using the Shapiro–Wilk test. The relationship between ABI or AHI and Rutherford grade was analyzed using Spearman’s correlation coefficient. Associations between clinical variables, including AHI, and Rutherford grade, were analyzed using univariate and multivariate ordinal logistic regression and expressed as odds ratio (OR) with 95% confidence interval. The univariate ordinal regression analysis for factors related to Rutherford grade included age, sex, height, weight, BMI, presence of diabetes, hypertension, or dyslipidemia, current smoking, history of hemodialysis or collagen disease, higher brachial SBP, heart rate, ejection fraction, hemoglobin level, creatinine, CRP, and APTT levels, PT-INR, routine use of low-dose aspirin, clopidogrel, cilostazol, warfarin, statin, or ACE inhibitors, and ankle SBP, DBP, PP, MAP, ABI, and AHI in the diseased limb. Independent baseline variables with a Significant stenotic lesions were detected on contrast angiography in the diseased limbs (n = 85) of the 85 patients . Patient characteristics, medical therapy, and Rutherford grade are shown in All ankle blood pressure parameters, including AHI, were obtained by measuring the ABI in the diseased lower limb of each patient. They are shown in r = 0.50, R2 = 0.25, P < 0.001) but not between Rutherford grade and ABI  was significant.As shown in r = −0.21, R2 = 0.04, P = 0.23, and diabetes: r = −0.12, R2 = 0.01, P = 0.40, respectively). However, in both groups, Rutherford grade correlated significantly with AHI  or those with diabetes (n = 54), ABI did not correlate significantly with Rutherford grade , regular hemodialysis , higher heart rate , lower hemoglobin level , higher creatinine level , higher CRP level , absence of statin treatment , lower ankle DBP , higher ankle PP , and higher AHI  were significantly associated with a higher Rutherford grade  was marginally associated with a higher Rutherford grade, whereas the association between a lower hemoglobin level  and higher AHI  and a higher Rutherford grade were significant  AHI, but not ABI, is significantly correlated with the Rutherford grade  and 2) anemia and increased AHI are independently associated with a higher Rutherford grade, as determined in a multiple ordinal regression analysis. These findings suggest that the AHI may objectively provide the severity of the blood supply limitation among PAD patients, and can be a useful supportive means to assess their symptoms, especially in those whose subjective symptoms are unreliable.Both the steady  and the pulsatile  components of arterial pressure  should bThe conduit function  where blood from the heart is delivered to capillaries of organs and tissues according to their need , is steaThus, the AHI, which reflects both the pulsatile  and steady  components, more closely reflects the degree of lower limb ischemia as assessed by the Rutherford classification. Based on a definition of the AHI as ankle arterial stiffness/ankle vascular resistance, both components, i.e., advanced arterial stiffness of the ankle and a decrease in ankle vascular resistance, including compensation by the collateral circulation, may result in an increased AHI. We suspect that the formation of collateral circulation or decreased vascular resistance may play a protective role to facilitate the blood supply in early stages; however, in cases with advanced ischemia, these systems may not satisfactorily afford blood supply to ischemic limbs. Therefore, AHI may also reliably predict a deficiency in the arterial blood supply. Indeed, in our study, there was a significant correlation between AHI and Rutherford grade in all 85 patients and the subgroup with a totally occluded iliofemoral artery or a history of diabetes.In contrast, the ABI, which reflects only the pulsatile component , does not necessarily reflect the degree of lower limb ischemia determined using the Rutherford classification. Thus, in patients with advanced ankle arterial stiffness due to arterial calcification or a decrease in arterial vascular resistance secondary to compensation by collateral flow , an undeThe Rutherford classification is used to assess the severity of lower limb ischemia in patients with PAD, in which arterial stenosis, occlusion, and calcified arteries are related to atherosclerosis , 12. ArtRed blood cells (RBCs) and circulating hemoglobin mediate physiological processes, including oxygen carrying capacity, but are also involved in pathophysiological pathways, such as inflammatory processes, oxidative stress, and blood viscosity disturbances . BecauseMeasuring blood pressure in the arteries of the ankle has become a standard part of the initial evaluation of the severity of the atherosclerotic burden in patients with PAD , 8. The This study has several limitations. First, the number of patients was limited because only those presenting with significant (>50%) stenosis in the lower extremity on contrast angiography and those with measurable ankle blood pressure were included. However, the number of included patients was sufficient to show a clear relationship between AHI and Rutherford grade. Second, the ABI was measured by oscillometric method, not by Doppler ultrasound method. However, according to the scientific statement from the American Heart Association, oscillometric method is also primarily used to detect limb flow and pulse volume for measuring the ABI . In addiThis study identified a significant correlation between the AHI, but not the ABI, and the Rutherford grade. Multiple ordinal regression analysis showed a significant and independent association of the AHI with the Rutherford classification. Our findings suggest that AHI, a novel parameter based on the ABI measurement, can be used to assess the arterial blood supply in the lower extremities of patients with PAD.S1 File(PDF)Click here for additional data file.


In multivariate analysis, the maximum systolic blood pressure was an independent predictor of postoperative hypertension urgency, and the cut-off point was 157 mmHg with the sensitivity of 66% and specificity of 82%. Multivariable analysis also showed that preoperative maximum systolic blood pressure and number of antihypertensive medicines were independent risk factors for higher postoperative systolic blood pressure. This study was derived from a high volume adrenal tumor center, and these data may provide a potential tool to guide preoperative counseling.Study about blood pressure variation in the first 24 hours post-operation is limited in patients with adrenal aldosterone-producing adenoma. We aim to evaluate the potential predictors for postoperative hypertension urgency during the first 24 hours after laparoscopic adrenalectomy in patients with aldosterone-producing adenoma. Clinical data of 177 patients with aldosterone-producing adenoma were retrospectively collected from January 2009 to December 2015 and the potential factors that may influence postoperative blood pressure during the first 24 hours after surgery were analyzed. The factors included gender, age, body mass index, preoperative maximum systolic blood pressure, number of antihypertensive medicines, preoperative spironolactone treatment, duration of hypertension, surgical method and approach, adenoma diameter, preoperative proteinuria, estimated glomerular filtration rate, serum potassium and serum aldosterone. Univariate and multivariate regression analyses were used to evaluate the relationship between the above variables and postoperative hypertension urgency. We found that the proportion of patients with a higher systolic blood pressure ≥ 160 mmHg and ≥ 180 mmHg were significantly increased post-operation (both  Among the general hypertensive population, primary hyperaldosteronism (PHA) is widely recognized as the most common cause of secondary hypertension . About 3Numerous studies have identified factors associated with long-term outcomes after adrenalectomy for PHA –10. HoweA total of 177 patients with APA were enrolled in this study. The demographic characteristics of the patients are shown in Table Laparoscopic partial or total adrenalectomy was successfully performed in all patients, 61.6% and 38.4%, respectively, without conversions to open surgery. Surgery was conducted by the transperitoneal approach in 39.5% of cases and retroperitoneal approach in 60.5% of cases. All 177 cases were pathologically confirmed to be benign adrenal cortical adenoma. There were no deaths or severe complications during hospitalization. The CT, specimen and pathology images of a typical APA case are shown in Figure The median concentration of serum aldosterone at diagnosis was 466 pg/mL (IQR = 306–700). The normal value of serum aldosterone at our center was 38–313 pg/ml in standing position. Thirty-one patients (17.5%) received intravenous antihypertensive medication in the immediate postoperative period because of persistent excessively high BP.p < 0.01. Hypertension urgency was seen in 29 (16.4%) patients after surgery, with a significant increase from 11 cases (6.2%) pre-operation.The systolic blood pressure(SBP) increased by a median of 20 mmHg (IQR = 5–28 mmHg) post-operation, and the median percentage was 13.4% (IQR = 3.3–20.4%). There were 91 patients (51.4%) with BP ≥ 160 mmHg post-operation as compared to 40 patients (22.6%) pre-operation, p = 0.001), duration of preoperative hypertension (< 5 years) (p = 0.001), surgical method (p = 0.043), and preoperative serum potassium (< 3.5 mmol/L) (p = 0.010) were associated with postoperative hypertensive urgency  was the only independent prognosticator . When the ROC curve of preoperative SBPmax was generated, the area under the curve was 0.771, consistent with good fit to the postoperative hypertension urgency data , number of antihypertensive medications (p = 0.032), duration of preoperative hypertension (< 5 years) (p = 0.007), and serum potassium (< 3.5 mmol/L) (p = 0.015) were associated with postoperative higher BP as a continuous variable (Table p = 0.045) and number of antihypertensive medications (p = 0.023) were independent prognosticators.On univariate analysis, preoperative SBPmax  or Urapidil Hydrochloride injection (2 mg/min) were the primary therapeutic options at our institution. Drip speed adjustment was made according to the real-time SBP. Timely intervention led to safe and efficient outcome, without cerebrovascular complications.High BP induced by hyperaldosteronism can be exacerbated in the immediate postoperative period by factors such as pain, hypercapnia, hypoxia, intravascular volume overload and hyperthermia , 16. In 2), hypertension (< 5 years duration), serum creatinine (< 0.8 mg/dL), and < 2 preoperative antihypertensive medicine [p < 0.05). The number of antihypertensive medicines was a meaningful parameter to predict the immediate and long-term BP variations. Considering SBPmax ≥ 180 mmHg as a categorical variable (whether hypertension urgency or not), only preoperative SBPmax was an independent prognosticator, p = 0.001.There was a trend of increase in BP after surgery due to several factors. Wachtel and colleagues evaluated several protective factors of persistent postoperative hypertension, including female gender, BMI  due to Asian ethnicity. Interestingly, we found that duration of hypertension was not a predictor for postoperative immediate SBP, which was inconsistent with previous reports on long-term hypertension , 14. DueIn conclusion, our data derived from the high volume adrenal tumor center and the results are relatively representative in population. The preoperative SBPmax was independently associated with hypertension urgency within the first 24 hours after laparoscopic adrenalectomy. These data may provide a potential tool to guide preoperative counseling. Control of preoperative SBP could decrease the occurrence of hypertension urgency within the first 24 hours post-operation.After approval by the Ethics Committee of Ruijin Hospital, the adrenal surgery registry database was used to identify patients who were managed with LA from January 2009 to December 2015. During this time, clinical data of 177 patients with APA were retrospectively collected at our adrenal disease center. Written informed consent was obtained from all enrolled patients. Before surgery, the patients underwent an examination in the department of Hypertension or Endocrinology. The diagnosis of PHA was based on endocrinological evaluation, preoperative imaging studies (CT or MRI) and postoperative pathology. Before endocrinological evaluation, mineralocorticoid receptor antagonists were washed-out for at least six weeks. Other antihypertensive drugs were replaced with verapamil (Isoptin) sustained-release tablets for at least two weeks. A positive diagnosis for PHA was based on elevated serum aldosterone level with increased aldosterone-to-renin ratio, and was confirmed by the absence of aldosterone suppression after a saline-loading test. All serum aldosterone concentrations were measured in a standing position, with normal value of 38–313 pg/mL at our center. Adrenal venous sampling (AVS) was conducted to distinguish between unilateral and bilateral adrenal lesions. Patients who refused to undergo AVS were excluded from this study. Each paraffin section and hematoxylin-eosin (HE) stained section was independently evaluated by two pathologists using standard criteria based on the WHO classification. The third independent pathologist adjudicated the section in case of different opinions.Laparoscopic total or partial adrenalectomy was performed via a standard transperitoneal approach in 70 patients and a retroperitoneal approach in 107 patients. The decision to perform a partial or total unilateral adrenalectomy was intraoperatively made based on the position of the adenoma in the adrenal gland and whether concomitant multiple microadenomas and nodules were presented , 20. Lap2) = 175× (serum creatinine)–1.234 × (age)–0.197(× 0.75 in case of women) [The potential risk factors included gender, age, body mass index (BMI), preoperative maximum systolic blood pressure (SBPmax), number of antihypertensive medicines, preoperative spironolactone treatment, duration of hypertension, surgical method and approach, adenoma diameter, preoperative proteinuria, estimated glomerular filtration rate (eGFR), serum potassium and serum aldosterone. BP was measured by the adjusted electronic sphygmomanometer routinely in our ward at least three times a day before surgery and then noted in the medical records. The preoperative highest SBP value was considered as a potential risk factor. Postoperative SBP was obtained via electrocardiogram monitors  as soon as the patients were transferred back to the wards during the first 24 hours post-operation. Semiautomatic noninvasive measurements of BP were performed every half an hour in the supine position. In this study, hypertension urgency was defined as SBP ≥ 180 mmHg , which tf women) . Preopert-test, Chi-square test, or Wilcoxon rank-sum test, as appropriate. Univariate analysis of risk factors for postoperative hypertension urgency and higher SBP was performed to detect the significant prognosticator. Then, multivariate analysis was used to evaluate the independent prognosticator. To dichotomize continuous variables, receiver operating characteristic (ROC) curves of independent prognosticators were generated, and values with maximal sensitivity were identified. The differences were considered significant if p < 0.05. Data were analyzed by using SPSS version 20.0 .Group comparisons were made using the Students’


Among the main causes of death in our country are car accidents, drowning andaccidental burns. Strangulation is a potentially fatal injury and an importantcause of homicide and suicide among adults and adolescents. In children, itsoccurrence is usually accidental. However, in recent years, several cases ofaccidental strangulation in children around the world have been reported. A2-year-old male patient was strangled in a car window. The patient was admittedto the pediatric intensive care unit with a Glasgow Coma Scale score of 8 andpresented with progressive worsening of respiratory dysfunction and torpor. Thepatient also presented acute respiratory distress syndrome, acute pulmonaryedema and shock. He was managed with protective mechanical ventilation,vasoactive drugs and antibiotic therapy. He was discharged from the intensivecare unit without neurological or pulmonary sequelae. After 12 days ofhospitalization, he was discharged from the hospital, and his state was verygood. The incidence of automobile window strangulation is rare but of highmorbidity and mortality due to the resulting choking mechanism. Fortunately,newer cars have devices that stop the automatic closing of the windows ifresistance is encountered. However, considering the severity of complicationsstrangulated patients experience, the intensive neuro-ventilatory andhemodynamic management of the pathologies involved is important to reducemorbidity and mortality, as is the need to implement new campaigns for theeducation of parents and caregivers of children, aiming to avoid easilypreventable accidents and to optimize safety mechanisms in cars with electricwindows. In recent years, several cases ofaccidental strangulation in children have been reported around theworld.Deaths related to external causes, such as car accidents, drowning and accidentalburns, in pediatric and adolescent patients are frequent, especially in childrenunder 1 year of age. In cases of strangulation, the comparison betweenadults and children shows that they have a lower risk of laryngeal and bonefractures due to elasticity but are more susceptible to airwayedema.,6Strangulation in children is an uncommon but extremely serious and potentially fatalevent due to its associated complications. After suffocation, there is a reductionin cerebral oxygenation, promoting varying degrees of edema, hemorrhage andischemia.-10 Although the strangulation of children instopped vehicles is poorly reported, this incident should be valued because it iseasily avoidable and reflects the education given by parents or caregivers tochildren regarding their safety.In the literature, events associated with asphyxia, such as accidents in sleepinghammocks, the automatic closing of electric windows in cars and suicide attemptswith ropes, among others, are described.In this study, the authors discuss the management and treatment of children who arevictims of strangulation caused by the automatic closing of automobile electricwindows, evolving with severe respiratory compromise, pulmonary edema and acuterespiratory distress syndrome (ARDS) but obtaining full recovery.Hospital das Clínicas de Porto Alegre,where he arrived unconscious, with hematemesis and cyanosis of the extremities andoral mucosa. He was admitted to the pediatric intensive care unit (ICU) with aGlasgow Coma Scale score of 8, progressive worsening of torpor and respiratorydysfunction. Orotracheal intubation was performed, and bleeding was visualizedthrough the tracheal tube. Under suspicion of an airway lesion due to local trauma,fibrobronchoscopy was performed, which did not reveal any structural alterations. Achest x-ray revealed bilateral pulmonary consolidations. The child's conditionevolved with progressive worsening and refractory hypoxemia, requiring increases inthe inspired oxygen fraction (FiO2) and ventilator parameters, with adiagnosis compatible with ARDS. Protective mechanical ventilation (MV) wasperformed, with positive end-respiratory pressure (PEEP) values between 12 and16cmH2O, associated with FiO2 values between 0.4 and 0.7.The child required progressively higher doses of vasoactive drugs. On the followingdays, a positive cumulative fluid balance was observed when a continuous infusion ofdiuretic was administered. This measure, together with keeping the child in a proneposition to manage the pulmonary ARDS, allowed the reduction of his MV parameters.Among the other treatments instituted were hypertonic solution instillation aimed atthe prevention of cerebral edema, because there was hypoxic ischemic injury in thebrain without a definite time frame, and antibiotic therapy for probable aspirationpneumonia. The MV and tracheal tube were suspended on the seventh day after theinjury, and the patient was maintained on noninvasive ventilation for 24 hoursimmediately after extubation, with progressive improvement and discharge from theICU in 10 days without neurological or pulmonary sequelae. After 12 days of hospitalstay, he was discharged from the hospital in great condition  or ropes; and other mechanisms. InWestern countries, strangulation is the third most common cause of accidentalchildhood deaths, 17% of which are caused by ropes and cables.There have been reports of Indian children being suspended by the cervical region inhomemade saree hammocks. In cases associated with longer times of strangulation,there was severe central nervous system impairment, long ICU stays and hospitaltimes and discharge with severe sequelae.,15 The prognosis depends on the severity and durationof the asphyxia. Mortality is high, and total neurological recovery has never beendescribed in patients with described cardiac arrest associated with strangulation.The goal is to maintain adequate cerebral blood flow so that brain cells, in turn,maintain aerobic metabolism, even when the patient is in a deepcoma.Considering the severity of asphyxia secondary to childhood strangulation, earlyidentification and appropriate management of complications are of paramountimportance. Brain damage and death are caused by airway obstruction, venouscongestion leading to hypoxia, acidosis, bronchopneumonia, cerebral edema andirreversible damage to brain cells. Pulmonary complications such as aspirationpneumonia, bronchopneumonia and ARDS are important causes of morbidity andmortality.-19 Therefore, in these cases, one of the recommendedinitial therapeutic measures is to increase serum osmolarity from the first momentsto balance the intra- and extracellular osmotic forces.,21Cerebral edema results from alterations due to failures in intracellular ioniccontrol, accumulation of sodium and water (cytotoxic edema) and control of flow andvascular permeability, leading to the accumulation of fluid in the cerebralinterstice (vasogenic edema). Early treatment of ICH aims to improve cerebralperfusion pressure, reduce the chances of herniation and improve neurologicaloutcomes. Among the measures we emphasize are the early use of hypertonic solutionfor neuronal protection, with increased serum osmotic pressure (serum sodium between155 - 165mEq/L); vasoactive drugs to optimize cerebral perfusionpressure, defined as a mean arterial pressure 50 - 60mmHg higher than theintracranial pressure (which in this case was estimated as 20mmHg); controlled MV;and pain/agitation control, with the use of continuous sedatives/analgesics.In the case of strangulation reported by us, despite the sensory alterations present,demonstrating impairment of the central nervous system, cranial tomography still didnot present the classic signs of cerebral edema and endocranial hypertension, namelyventricular reduction or collapse, disappearance of cortical sulci and diffuseedema, associated or not with hemorrhagic areas. This absence of suggestive classicimages on tomography is not uncommon in the initial post-injury moments and shouldbe interpreted as the phases of the establishment and progression of cytotoxic andvasogenic edema, which may culminate with intracranial hypertension(ICH).The major osmotic agents for treating cerebral edema include mannitol and hypertonicsaline. Mannitol is indicated in situations of acute hypertensive crises. However,because mannitol is an osmotic diuretic, it can cause hypotension and reducecerebral perfusion. Hypertonic saline solution does not have the diuretic effect ofmannitol; its mechanism involves increased serum osmolarity and consequent increasesin the mean systemic blood pressure and cerebral perfusion pressure. It is now knownthat increases in sodium are not deleterious, as seen in the rapid correction ofhyponatremia. In this situation, values close to 165mEq/L are safe and effective,without major adverse effects. We chose to start with an infusion of 0.1 -1mL/kg/hour of 3% solution, reaching serum sodium concentrations between 150 -165mEq/L.2O) haslittle effect on the intracranial pressure of ICH patients.,26 This finding can beexplained by fluid mechanics, where a positive end-expiratory pressure (PEEP) of13cmH2O equals a pressure of 10mmHg, which is lower than the pressureat which it is defined as ICH (> 20mmHg). Thus, even in the presence of 13 -15cmH2O PEEP (inside the thorax), there would be venous flow in thecentral nervous system towards the thorax. Therefore, the use of PEEP (8 -14cmH2O) allows the alveoli to remain open, improving oxygenation,reducing pulmonary vascular resistance and promoting better ventilation/perfusionratios in patients with pulmonary lesions compatible with ARDS and cerebraledema.-28A frequent complication in these cases is the presence of aspiration pneumoniaassociated with ARDS. In this case, the dilemma of optimizing pulmonary treatmentwith increased intrathoracic pressures and, consequently, reducing venous drainageor using a less protective ventilation technique can be established to maximizevenous return of the central nervous system. Some time ago, it was shown that theuse of positive expiratory pressure (levels of 5, 10 and 15cmHIn this report, the risk and severity of the complications of strangulated patientswere evident. Their management should be oriented towards the optimization andpreservation of hemodynamic, ventilatory and neurological functions. Efforts shouldbe made to implement educational campaigns for parents and caregivers of children toavoid easily preventable accidents and to improve safety mechanisms in cars withelectric windows.


To investigate the blood pressure dynamics after renal denervation through monthly home blood pressure measurements throughout the first 12 months.A cohort of 70 patients performed highly standardized monthly home blood pressure monitoring during the first year after denervation according to the European Society of Hypertension guidelines. At baseline and 12 months follow-up, office and ambulatory blood pressure as well as routine physical and laboratory assessment was performed.Home blood pressure decreased with a rate of 0.53 mmHg/month (95% CI 0.20 to 0.86) systolic and 0.26 mmHg/month (95% CI 0.08 to 0.44) diastolic throughout 12 months of follow-up, while the use of antihypertensive medication remained stable . On average, a 12 month reduction of 8.1 mmHg (95% CI 4.2 to 12.0) was achieved in home systolic blood pressure, 9.3 mmHg (95% CI -14.2 to -4.4) as measured by 24-hour ambulatory blood pressure monitoring and 15.9 mmHg (95% CI -23.8 to -7.9) on office measurements.Blood pressure reduction after renal denervation occurs as a gradual decrease that extends to at least one-year follow-up. Home monitoring seems a suitable alternative for ambulatory blood pressure monitoring after renal denervation. Hypertension is common in the western society and the risk of vascular complications is strongly related to blood pressure levels. As the gIn 2009, catheter-based renal denervation (RDN) was introduced as a new, promising treatment for patients with persistent hypertension despite comprehensive pharmacological treatment. InitiallAmong these issues is the uncertainty when to expect a response of RDN on blood pressure. It is unknown whether BP acutely decreases shortly after the intervention or more gradually over the course of several months. Therefore, we investigated home blood pressure measurements (HBPM) throughout the first year after RDN treatment to elucidate the dynamics of BP following RDN.This study was conducted at the University Medical Centre Utrecht and is part of the Dutch National Renal Denervation Registry (NCT02482103) that was approved by the Medical Ethics Committee of the UMC Utrecht. The regiFor the current analysis, we studied a cohort of consecutive patients that performed HBPM throughout the first year after RDN for resistant hypertension  or the inability to be adequately treated for hypertension due to recorded intolerance for antihypertensive drugs (non-resistant hypertension). Before intervention, all patients were subjected to a thorough screening procedure including 24-hour ambulatory blood pressure monitoring (ABPM), to exclude pseudo-resistant hypertension, significant white coat effect and secondary causes, as previously described.[The final decision for eligibility for RDN was made by a multidisciplinary team, consisting of a vascular medicine specialist (WS), a nephrologist (PB), an interventional cardiologist (MV) and an interventional radiologist (EJV). Major exclusion criteria included ineligible renal artery anatomy, an estimated glomerular filtration rate (eGFR) <30 mL/min/1.73m², severe co-morbidity and patient refusal. The RDN To perform HBPM, patients received an automated WatchBP Home device . Patients were instructed according to the European Society of Hypertension recommendations,19 to peHBPM measurements were to be taken in a seated position after 5 minutes of rest, two times in the morning (6-9AM) and two times in the evening (6-9PM) during seven consecutive days. All measurements were automatically stored to the device and uploaded to a secure internet site . Patients were unable to add, delete or change any measurements on the device or on the BP@home server. In accordance to the guidelines,19 measuThe BP measurements from each HBPM period of seven days were used to calculate the mean systolic (SBP) and diastolic (DBP) home BP for each month. Medication use for each period was recorded based on prescription history and detailed history taking. Prescribed dosages of antihypertensive drugs for each time point were converted into defined daily doses (DDD) using conversion factors provided by the World Health Organization (WHO) Drug Classification. The cumOffice BP, laboratory results, medical history and physical examination were registered during screening and at six and 12 months follow-up. Ambulatory BP monitoring was performed during screening and 12 months follow-up. A subgroup of patients repeated the medication-free period at 12 months follow-up as part of a different study protocol. All BP mResults are presented as mean ± standard deviation or as absolute number with percentages, unless otherwise specified.Multilevel linear mixed effect models were used for analysis of BP over time. This model has several advantages in modelling changes over time over a repeated measures ANOVA. In particular the model is not hampered by missing data and it provides estimation of effect size and precision. Time in For body mass index, eGFR, office BP and ABPM the change between baseline and 12 months follow-up was assessed by means of the paired samples T-test, or Wilcoxon signed rank test when appropriate.Results were considered statistically significant if the 95% confidence interval (CI) did not include 0 or if the two-tailed probability value  did not exceed 0.05. All analysis was performed with SPSS statistical software version 22 .Our registry included 118 patients who were treated with RDN between June 2010 (the start of RDN at our facility) and May 2014. As of May 2011, all patients (n = 90) consecutively received an automated device to perform HBPM. Sixteen patients refused HBPM or did not have access to internet, resulting in 74 patients of whom HBPM was available. Four patients only performed measurements during the screening procedure and were excluded from analysis.Characteristics of the remaining 70 patients are shown in Overall, the amount of antihypertensive medication prescribed decreased from 5.8±3.8 DDD at baseline to 5.3±3.6 DDD at 12 months with a mean difference of 0.5 (95% CI -1.3 to 0.2). There was no change in eGFR  or BMI  between baseline and 12 months follow-up. In addition, there was no change in urinary sodium excretion , although follow-up urine analysis was only available for 29 subjects.Mean HBPM values decreased from 181/104 mmHg (SD 19/13) during the medication-free screening period before RDN to 158/92 mmHg (SD 17/13) one week after RDN and 152/87 mmHg (SD 21/13) at one year follow-up. Due to the medication-free baseline screening, the DDD differed from the baseline measurement to 1 week after renal denervation (0.5 vs 4.3), but remained stable from week 1 through month 12 .The unconditional mixed model (model I) showed a significant change in BP of -0.56 mmHg/month after RDN (95% CI -0.89 to -0.24) for SBP and -0.27 mmHg/month for DBP (95% CI -0.46 to -0.07) during the 12 months after treatment . In the Heart rate changed significantly in the unconditional model, but this change was not clinically relevant (-0.09 bpm per month) nor statistically significant after correction for pre-specified variables. Results for the different subgroups are shown in Our results show a number of important observations. First, a gradual decrease in BP following RDN was observed over the course of 12 months. Second, the observed decrease did not reach an obvious plateau during our follow-up and was unaffected by changes in the amount of antihypertensive medication. Lastly, the rate of change in home BP measurements and 24-hr ambulatory BP measurements was comparable, while office measurements appeared to be higher throughout the study.These results provide an answer in the debate concerning the timing of the effect of RDN. It has been stated by some that RDN has a rapid effect during the first trimester, while others have advocated that the effect may take several months to occur.,26 In prAn interesting finding in our study is that, in contrast to patients with resistant hypertension, patients with medication intolerance did not show a decrease  in blood pressure. This is in contrast to the findings of De Jager et al, who demonstrated significant decreases in office and ambulatory blood pressure in a small cohort of patients not taking AHD. ObtaininHBPM also has additional value in hypertension research. Previous studies in the field of RDN have mostly used office BP measurements as an endpoint. However, it is known that office BP measurements are subjected to several disadvantages, such as observer bias and white coat effect. Even when performed under ideal circumstances, such as proper positioning of the patient, well-trained personnel and selection of the correct cuff size, office BP readings have poor reliability and tend to overestimate true BP.–33 This Randomised sham-controlled trials, such as the HTN-3 trial and the We studied blood pressure changes after RDN using HBPM, which is considered more reliable than office measurements and has not yet been widely used in RDN research. Using HBPM also minimized the influence of regression-to-the-mean in our analysis, because the effect of this statistical phenomenon quickly diminishes after a few readings and HBPMwhen BP reduction occurs after RDN, but we cannot provide an answer in the discussion whether the observed effect is caused by the intervention. Although we did observe an apparent drop in BP between baseline and the first measurement after RDN (one week post-RDN), this observation is biased by an artificial increase in antihypertensive medication caused by the medication free screening period and therefore not included in the LMM analysis. Therefore, we can neither rule out nor demonstrate the coexistence of an acute drop in BP during the first days.As stated in the introduction, recent trials raised several issues concerning the effectiveness of RDN, including technical aspects, anatomical issues, patient selection, study design and timing of the BP response. In the current analysis we were able to address the latter, but other aspects remained unaddressed. As long as a quantitative measure for the extent of nerve damage effectuated by the RDN procedure is lacking, any statements concerning causality are highly speculative. Therefore, we can make a statement regarding Lastly, we did not include a control group and therefore cannot compare the BP effect in our intervention group to BP control measured by HBPM in a hypertensive population without intervention. The observed BP effect in our study was modest and the use of HBPM may have contributed to the BP reduction as it may not only be used as a diagnostic, but also as an educational tool. Especially when combined with telemonitoring, HBPM can contribute to better BP control and the need for less antihypertensive medication.–39 HowevIn this study we have evaluated BP dynamics the first year after RDN. Using frequent home BP monitoring in a real life setting we demonstrated a gradual decrease over time after RDN. Future research needs to distinguish whether this decrease represents a true effect of RDN, or whether it is effectuated through other factors as discussed above. Particularly in hypertension research, the use of a randomized sham-controlled design and reliable BP measurements is key. For outcome measurement in these studies, HBPM may be a more informative and convenient alternative to ABPM. However, it is important to realize that any statements concerning causality between the RDN procedure and the observed effect on BP are highly speculative as long as a quantitative measure for the extent of nerve damage is lacking.


Hypertension and chronic kidney disease (CKD) are common conditions and both are major risk factors for cardiovascular events. The objectives were 1) to study the prevalence of CKD in hypertensive patients and 2) to study the association of CKD with cardiac and vascular complications in a multicenter, nation-wide fashion.This cross-sectional study evaluated patients aged 20 years or older who were diagnosed with hypertension and who had been treated for at least 12 months at 831 public hospitals in Thailand during the 2012 study period. Outcome measurements included calculated glomerular filtration rate (GFR) and cardiac and vascular complications that included coronary artery disease, stroke, peripheral arterial disease, heart failure, and atrial fibrillation. Multivariable modeling was conducted to determine independent factors associated with increased risk of cardiac and vascular complications.A total of 28770 patients were enrolled. Average age was 62.8 years and 37% were male. Prevalence of CKD stage 3 and 4–5 was 33.2 and 4.3%, respectively. Prevalence of cardiac and vascular complications was 10.5% . CKD was an independent risk factor associated with each of the complications and overall cardiac and vascular complications with an adjusted Odds ratio of 1.4 for CKD stage 3 and 1.9 for CKD stage 4–5.Prevalence of CKD stage 3–5 in hypertensive population was 37.5%. CKD is an independent risk factor for adverse cardiac and vascular outcome. Chronic kidney disease (CKD) is a leading cause of morbidity and mortality among patients around the world . PrevaleCKD is classified into 5 stages; CKD stages 1 and 2 have a glomerular filtration rate (GFR) of higher than 60 ml/min. The GFRs of CKD stages 3, 4 and 5 are 30–60, 15–30 and < 15 ml/min respectively [Recent practice guidelines for cardiovascular prevention regarded CKD as a major risk factor for cardiovascular event . CKD staThe primary objective of this study was to determine the association between CKD and cardiac and vascular complications in hypertensive patients. The secondary objectives were to: 1) study the prevalence of CKD in hypertensive patients; and 2) study the prevalence of cardiac and vascular complications in patients with hypertension.This cross-sectional survey was conducted in Thailand in 2012 to evaluate nation-wide standard of care and treatment outcome among hypertensive patients who were treated at public Thailand Ministry of Public Health (MoPH) hospitals in Thailand and private clinics in Bangkok that participate in the Thailand National Health Security Office (NHSO)’s program. Patients were enrolled if they were diagnosed with hypertension, aged 20 years or older and received regular treatment in the participating hospital or clinic for the past 12 months. All patients were recruited from the ambulatory unit. We excluded patients participating in clinical trials.We used a two-stage stratified cluster, proportional to the size sampling technique, to select a nationally and provincially representative sample of patients who were diagnosed as hypertension. In provinces outside of Bangkok, participating hospitals included all public hospitals under the oversight of the Thailand Ministry of Public Health (MoPH). For Bangkok, targeted hospitals included all hospitals and clinics that were participated in the Thailand NHSO program. The sampling started at the first stage of 77 strata at the provincial level. The second stage was at the hospital level in each province. In each province, hospitals were stratified into 5 strata, according to sizes. The largest size was more than 500 beds  followed by 200–500 beds , 90–120 beds , 30–90 beds , and 10–30 beds . University hospitals were not included from our study.This study was approved by the Royal Thai Army Medical Department Ethical Review Board, the Ethical Review Committee for Research in Human Subjects, Thailand Ministry of Public Health. The protocol for this study was also approved by the Institutional Review Boards of all participating hospitals. Written informed consent was obtained from subjects prior to participation. This study was supported by the Thai National Health Security Office (NHSO).A total of 831 hospitals under the Thai Universal Coverage Scheme were included. The number of regional hospitals, general hospitals and community hospitals were 25, 70, and 736 respectively. Every regional and general hospital was included. Community hospitals were randomly sampled with 70% of small-sized hospitals, 20% of medium-sized hospitals and 10% of large-size community hospitals. These proportions were based on the proportion of health care provided at various hospitals levels. Patients diagnosed as hypertension were randomly selected according to the proportion that were registered at each hospital. Sample size of the study was derived from the proportion to size model.To minimize the selection bias, all patients who were randomly selected was invited by the study nurse to participate in this study. Data were retrieved from patient’ medical records, which included baseline characteristics, presence of hypertensive complications, and laboratory test results. The study nurse was trained for the process of data collection. The required data were retrieved from medical recorded and entered in the case record form (CRF). Entry of data in the CRF was based on data that were written in the medical record or from the ICD-10 diagnostic code. This applied to diagnosis of hypertension and all other diagnoses. A majority of participating hospitals had medical record in non-electronic format limiting the opportunity of data transfer from hospital electronic database. The case record form was then sent to the central data management or MEDRESNET . Data management officers at MEDRESNET manually adjudicated the data and ensured that the data in the case record form complied with the study protocol. In case of doubt the query was sent to study site to verify with the data in the medical record.Glomerular filtration rate (GFR) was calculated by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula , 14. GFRThe following variables were collected: demographic data; height; weight; body mass index (BMI); cardiovascular risk factors; systolic blood pressure (SBP); diastolic blood pressure (DBP); blood chemistry, including fasting plasma glucose (FPG), lipid profiles, serum creatinine, uric acid, proteinuria from urine analysis; available ECG data and results. The laboratory results were the most recent results within 12 months prior to the consent process.The data management team is responsible for inquiries to study sites to verify data. By a random selection process, site monitoring was performed in approximately 60 hospitals or 10% of study sites.Primary outcome measurements were cardiac and vascular complications, which included coronary artery disease (CAD), stroke, peripheral arterial disease (PAD), heart failure, and atrial fibrillation. CAD was defined as angina pectoris, myocardial infarction, or coronary revascularization. Stroke was defined as cerebral infarction, TIA, unspecified stroke, or hemorrhagic stroke. Vascular complication was defined as CAD, stroke, or PAD. Secondary outcomes were defined as individual components of cardiac and vascular complications.t-test. Comparisons were performed by chi-square test for categorical data. Continuous data were grouped for Odds ratio analysis, as follows: age ≥ or < 65 years, SBP ≥ or < 140 mmHg, DBP ≥ or < 90 mmHg, TC ≥ or < 200 mg/dl, TG ≥ or < 200 mg/dl, HDL < or ≥ 40 mg/dl, LDL ≥ or < 100 mg/dl, BMI ≥ or < 25 kg/m2, GFR < or ≥ 60 ml/min, and uric acid ≥ or < 7 mg/dl in male and ≥ or < 6 mg/dl in female. When missing data were detected during data entry, query of raw data was sent to the study site for verification. During data analysis, since the number of patients is large and number of missing data was small in the majority of data as shown in Table Continuous data were presented as mean and standard deviation and categorical variables were expressed as number and percentage. Comparisons of continuous data were performed by independent samples p-value less than 0.05 was considered statistically significant. All statistical analyses were performed using SPSS Statistics version 20 .Odds ratio and 95% confidence interval (CI) for univariate analysis were determined by chi-square test. Multivariate logistic regression analysis (with forward LR) was used to determine the independent factors that are associated with increased risk of cardiac and vascular complications using complete-cases analysis with and without imputation method for the missing data. For imputation method, missing values were imputed by using the means of complete cases with noise added based on the t-distribution. CKD was tested to determine whether or not it was an independent risk factor associated with cardiac and vascular complications after adjustment for other baseline characteristics. A There were a total of 28770 patients; with a mean age 62.8 ± 11.3 years; 10650 (37.0%) of our subjects were male. Average GFR was 68.3 ± 22.8 ml/min; ≥60 ml/min in 17970 (62.5%), 30–59 ml/min in 9553 (33.2%), and <30 ml/min in 1247 patients (4.3%). Prevalence of CKD stage 3 and stages 4–5 increased with age . Odds ratios and a forest plot indicating the association of each of the baseline characteristics with cardiac and vascular complications are shown in Fig. p < 0.05). Crude and adjusted Odds ratio of factors that were independently associated with cardiac and vascular complications is shown in Table Baseline characteristics, blood chemistry data, control status of cardiovascular risk factors and prevalence of cardiac and vascular complications in each group are shown in Table Data on proteinuria was available in only 2281 patients (7.9%). Among patients who had available urine protein data, the results were negative or trace in 874 (38.3%), 1+ in 768 (33.7%), 2+ in 447 (19.6%), 3+ in 159 (7.0%), and 4+ in 33 (1.4%). Since the number of patients with available urine protein data was relatively small, we did not intend to run the primary outcome analysis for proteinuria. However, among patients with urine protein data, proteinuria had an Odds ratio for the association with cardiac and vascular complication of 1.20 (95% CI 0.92–1.58). The numerical association of proteinuria and cardiac and vascular complication was mainly for patients with CKD with the Odds ratio of 1.23 (95% CI 0.84–1.1.80) compared to those without CKD .Multivariable adjusted Odds ratio and 95% CI for association of levels of GFR with each factor of cardiac and vascular complication are shown in Fig. The results of this study demonstrated prevalence of CKD stage 3 and 4–5 in patients with hypertension to be 33.2 and 4.3%, respectively. A decline in GFR in patients with hypertension was independently associated with cardiac and vascular complications which included CAD, stroke, PAD, and heart failure.Prevalence of CKD has increased over the past 20 years  as a resOur study showed prevalence of CKD stage 3 and stages 4–5 in patients with hypertension of 33.2 and 4.3% respectively. Mean age in our study population was 62.8 years. Previous study in healthy Thai individuals from the NHES study showed prevalence of CKD stage 3 and stages 4–5 of 8.1 and 0.35%, respectively . HoweverPatients with CKD stage 3B or 4  had a decreased life expectancy of 17 and 25 years, respectively  in compaMany mechanisms facilitate and contribute to increased cardiovascular risk in CKD. Patients with CKD were commonly found to have concomitant cardiovascular risk factors, such as diabetes and hypertension. Patients with CKD had increased activation of renin-angiotensin and sympathetic response compared to those with normal renal function , 26. MorRecent report shows a high prevalence of CKD in hypertensive patients and a strong association of CKD and cardiac and vascular complication . This stOur study had some limitations. This was a cross-sectional study. We did not collect medication data such as anti-hypertensive medications, anti-thrombotic medications, and statins. The nature of our study design cannot prove cause and effect of identified associations. This study was designed for a cross-sectional survey and did not plan for a collection of follow-up data. Therefore we did not collect short or long-term outcome or changes in GFR or proteinuria. In fact, the main purpose of the main study was to determine the rate of blood pressure goal achievement and to feedback to the participating hospitals how good they are for blood pressure control. This study collected data from hospital based samples which may over-estimate the prevalence obtained from community based individuals. All patients were recruited from the ambulatory setting. Therefore the probability of recruiting acute kidney injury (AKI) cases should be very low since AKI cases should be admitted and managed in hospital setting. However, undetected AKI may be missed. The associations between cardiac and vascular complications with low cholesterol, low LDL-cholesterol, low triglyceride, and high HDL-cholesterol could be due to the effect of statin use, which would be more commonly found in patients with cardiac and vascular disease. This could make some results of our study difficult to interpret. Methods of creatinine measurement were not the same across all participating centers. Approximately half of the centers used enzymatic method for the measurement of serum creatinine and another half used modified Jaffe method. Enzymatic method was IDMS (isotope dilution-mass spectrometry)-traceable. Although the method that was used in many centers were not IDMS-traceable but all centers had their own laboratory standard quality control system that applied to local practice. Lastly, there were some cases with missing data, since it was not mandatory to have every variable entered into the case record form.In conclusion, prevalence of CKD in our hypertensive population was 37.5%. CKD is an independent risk factor that is associated with many cardiac and vascular complications. Improved awareness regarding detection and management of CKD is very important, especially for primary care physicians.


Background: Organizational and educational activities in primary care in Poland have been introduced to improve the chronic heart failure (CHF) management.Objectives: To assess the use of diagnostic procedures, pharmacotherapy and referrals of CHF in primary care in Poland.Methods: The cross-sectional survey was conducted in 2013, involving 390 primary care centres randomly selected from a national database. Trained nurses contacted primary care physicians who retrospectively filled out the study questionnaires on the previous year’s CHF management in the last five patients who had recently visited their office. The data on diagnostic and treatment procedures were collected.Results: The mean age ± SD of the 2006 patients was 72 ± 11 years, 45% were female, and 56% had left ventricular ejection fraction <50%. The percentage of the CHF patients diagnosed based on echocardiography was 67% and significantly increased during the last decade. Echocardiography was still less frequently performed in older patients (≥80 years) than in the younger ones  and in women than in men . The percentage of the patients treated with β-blocker alone was 88%, but those with a combination of angiotensin inhibition 71%. The decade before, these percentages were 68% and 57%, respectively. Moreover, an age-related gap observed in the use of the above-mentioned therapy has disappeared.Conclusion: The use of echocardiography in CHF diagnostics has significantly improved in primary care in Poland but a noticeable inequality in the geriatric patients and women remains. Most CHF patients received drug classes in accordance with guidelines. KEY MESSAGESMore attention is needed to include echocardiography in diagnostics of CHF in older patients, also due to a higher prevalence of chronic comorbidities associated with preserved ejection fraction.Most CHF patients received drug classes in accordance with guidelines, and no age/gender-related gap was observed in the neurohormonal blockade.Chronic heart failure (CHF) affects about 26 million adults in the world , approxiDo Polish primary care physicians have access or perform basic diagnostic procedures for CHF patient?What are the drugs prescribed to CHF patients by Polish primary care physicians?What is the rate of referrals to the secondary care of CHF patients seen by primary care physicians?Have diagnostic and therapeutic procedures for CHF patients changed since the previous survey dated in 2005?Within the National Programme for Prevention of Cardiovascular Diseases (POLKARD 2005), a series of nationwide surveys was conducted in randomly selected primary care settings to assess adherence to guidelines on CHF management with regard to the diagnosis and treatment procedures . The chaThe study was a nationwide, retrospective survey performed according to the principles of the previous survey edition in 2005 ,11. A trhttps://rpwdl.csioz.gov.pl—in April 2013. Out of all settings providing primary care a proportional stratified multistage sample of 390 primary care centres was selected. Random selection was held in each stratum defined by the province and size of the town in such a way that the number of primary care centres was proportional to the fraction of the population that the stratum constitutes in the general population. In the selected primary care centre, the physicians were randomly chosen from the list of primary care physicians employed in the centre.The sampling frame was the Polish nationwide registry of entities carrying out medical activities available at Patients who had ever been diagnosed with CHF were included in the study. The diagnosis of CHF had to be available in the patients’ medical records and the primary care physician had to be convinced of the presence of CHF  and treated that patient during the previous year as a CHF patient. CHF did not have to be the direct reason for encounter. A currently treated oncologic condition was a criterion for exclusion from the study.t-test or the Wilcoxon test, and the chi-square test. The Cochrane–Armitage trend test was used to assess age-related changes in pharmacological therapy of CHF. Two-sided tests were used and the P-value <0.05 was considered as significant.Continuous variables were summarized as mean ± standard deviation (SD). Ordinal variables or variables with skewed distribution were presented as median and interquartile range (IQR). Data on prevalence were given as numbers (percentages). The comparative analyses were based on Student’s Data were managed and analysed using SAS v. 9.3 .Data were collected and processed maintaining confidentiality and anonymity of the surveyed patients and the primary care physicians participating in the study. The study was approved by the Bioethics Committee of the Jagiellonian University —opinion dated 28 June 2012, and was valid until 31 December 2013.The surveyed primary care centres mostly operated within the structures of private healthcare institutions, acting as an independent contractor within the public healthcare system. The participating physicians were mostly family physicians (63%) and specialists in internal medicine (38%), 7% were cardiologists and 2% were geriatricians.The mean age (± SD) of the 2006 surveyed CHF patients was 72 years (± 11); 45% were women, 74% had ischaemic history of CHF. The baseline characteristics of the patients was summarized and compared from the study population from 2005 in P <0.001) and in very old patients (≥80 years) than in younger subjects . The data from the last echocardiography of the surveyed CHF patients, available for primary care physicians has shown the median of the left ventricular ejection fraction (LVEF) equal to 45% (interquartile range: 35–55%). Of these, 43% have the normal ejection fraction.The diagnosis of CHF was supported by echocardiography in 67% of the patients in primary care settings surveyed in 2013, although the small changes regarding to the accessibility of the echocardiography in primary care settings were observed . In geneAccess to the serum concentration of N-terminal of the prohormone BNP (NT-proBNP) has improved, although it was still infrequently used in primary healthcare and the procedure was made only in a small group of patients .During the year preceding the survey 24-h ECG was performed in 24% patients, spirometry in 17%, an exercise stress test in 19%, and 4% of the patients had undergone ergospirometry or the six-minute walk test. In addition, 77% of the CHF patients were referred to cardiologists, however with advancing age, the frequency of the referrals steadily decreased—from 92% in patients below 50 years of age to 70% among octogenarians, and 60% in 90-year-old patients. To psychologists, physiotherapists or dieticians were referred respectively 10%, 8% and 4% of the patients. During the last visit, primary care physicians recognized functional disability, cognitive decline and depressive symptoms, in respectively: 31%, 21% and 8% of the patients.Usage of the drug classes dedicated to CHF therapy as well as other cardiovascular medications was summarized in P < 0.001).There were no significant differences between women and men in the use of angiotensin inhibition therapy and β-blockers , as well as in MRAs and digitalis use. The only difference was in the use of diuretics—frequently more in women than men . Moreover, the percentages of CHF patients on digitalis therapy were decreased, whereas with age a more frequent use of diuretics and less frequent use of MRAs were observed.A significant increase in the use of β-blockers alone or with angiotensin inhibitions were observed when compared to the previous survey from 2005 as well as the loss of discrepancies in the use of β-blockers in younger and older patients  and probably the optimal doses of drugs. Given that the CHF population is getting older, a further educational effort is needed to improve the implementation of geriatric evaluation basis to the clinical practice of family physicians.During the last decade, an improvement in the use of echocardiography in CHF diagnostics in primary care has been observed in Poland, although its accessibility has not improved. A minority of the primary care centres declared access to NT-proBNP measurement and only a few percent of the CHF patients had this diagnostic test performed. There still exists an inequity in performing echocardiography concerning geriatric patients and women. Such disparities were not visible in the first-line CHF treatment drug classes. Most CHF patients received drug classes in accordance with guidelines.Click here for additional data file.