Birth weight and blood pressure in childhood: results from the Health Survey for England.

Primatesta P, Falaschetti E, Poulter NR.

Department of Epidemiology and Public Health, University College London Medical School,Gower Street Campus, 1-19 Torrington Place, London WC1E 6BT, UK. p.primatesta ucl.ac.uk

Findings of previous reports relating low birth weight with raised blood pressure in childhood and adolescence have been inconsistent. The present study uses cross-sectional data from a series of nationally representative annual surveys--the Health Survey for England--between 1995 and 2002, totaling a sample of 15 629 children aged 5 to 15. A significant negative relationship between birth weight, in quartiles or dichotomized as low (<2.5 kg) and normal (> or =2.5 kg) and systolic blood pressure was apparent. Linear regression analyses confirmed these findings. When current weight was included in the model, the strength of the relationship increased. An interaction term between birth weight and current weight was not significant. A life-course plot for those aged 13 to 15 (n=3900), converting the weight measurements at birth and as a teenager to standard deviation scores to make the regression coefficients comparable, showed the importance of weight gain on blood pressure (1 standard deviation increase in weight from birth to age 13 to 15 was associated with an increase in systolic blood pressure of 0.8 mm Hg). Separating those with low and normal birth weight demonstrated that the increase in weight from birth to adolescence had an effect on blood pressure in both those with low and normal birth weight. Postnatal changes in size have a more important effect on blood pressure in childhood and adolescence than birth weight. Reducing the prevalence of overweight among children may reduce their systolic blood pressure importantly and, particularly among children with lower birth weight, the prevalence of hypertension later in life.

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Maternal protein intake is not associated with infant blood pressure.

Huh SY, Rifas-Shiman SL, Kleinman KP, Rich-Edwards JW, Lipshultz SE, Gillman MW.

Department of Ambulatory Care and Prevention, Harvard Medical School/Harvard Pilgrim Health Care, 133 Brookline Avenue, 6th floor, MA, USA.

BACKGROUND: Animal data show that low protein intake in pregnancy programs higher offspring blood pressure, but similar data in humans are limited. We examined the associations of first and second trimester maternal protein intake with offspring blood pressure (BP) at the age of six months. METHODS: In a prospective US cohort study, called Project Viva, pregnant women completed validated semi-quantitative food-frequency questionnaires (FFQ) to measure gestational protein intake. Among 947 mother-offspring pairs with first trimester dietary data and 910 pairs with second trimester data, we measured systolic blood pressure (SBP) up to five times with an automated device in the offspring at the age of six months. Controlling for blood pressure measurement conditions, maternal and infant characteristics, we examined the effect of energy-adjusted maternal protein intake on infant SBP using multivariable mixed effects models. RESULTS: Mean daily second trimester maternal protein intake was 17.6% of energy (mean 2111 kcal/day). First trimester nutrient intakes were similar. Mean SBP at age 6 months was 90.0 mm Hg (SD 12.9). Consistent with prior reports, adjusted SBP was 1.94 mm Hg lower [95% confidence interval (CI) -3.45 to -0.42] for each kg increase in birth weight. However, we did not find an association between maternal protein intake and infant SBP. After adjusting for covariates, the effect estimates were 0.14 mm Hg (95% CI 20.12 to 20.40) for a 1% increase in energy from protein during the second trimester, and 20.01 mm Hg (95% CI 20.24 to -0.23) for a 1% increase in energy from protein in the first trimester. CONCLUSIONS: Variation in maternal total protein intake during pregnancy does not appear to program offspring blood pressure.

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Cardiovascular effects of thyroxine in combination with methimazole in premenopausal female Graves' disease patients: case-control study.

Karner I, Stefanic M, Topuzovic N.

Department of Nuclear Medicine, Osijek University Hospital, J. Huttlera 4, 31000 Osijek, Croatia.

AIM: To evaluate cardiovascular consequences of combined treatment in Graves' disease patients with addition of thyroxine (LT4) to antithyroid drugs in doses sufficient to suppress serum thyrotropin (TSH) levels below normal. METHODS: Eleven premenopausal female patients who reached subnormal TSH levels (<0.3 microIU/mL) under the combined therapy were evaluated by equilibrium radionuclide ventriculography at rest, and during the peak stage of fixed moderate exercise workload (75W) initially at diagnosis and after at least 8 months of stable euthyroidism, as judged by peripheral free thyroxine and triiodothyronine. The control group included 12 euthyroid healthy women. RESULTS: Post-treatment resting systolic and diastolic blood pressure, heart rate, and left ventricular (LV) systolic function were similar to control values. Log-transformed TSH releasing factor-stimulated TSH response correlated with LV resting early diastolic peak filling rate (PFR) (r=0.802, p=0.003) and resting diastolic blood pressure (r=0.795, p=0.003), which, in turn, was a significant predictor of basal renin secretion (r=-0.84, p=0.001). Treated patients had increased peak exercise systolic blood pressure (median 175, interquartile range 25 vs median 156, interquartile range 29 mmHg, p=0.019), delayed recovery of post-exercise heart rate to basal levels, and reduced exercise ejection fraction (median 66, interquartile range 9 vs median 74, interquartile range 13 %, p=0.037) in comparison with controls. Exercise ejection fraction was inversely related to exercise diastolic blood pressure, (r=-0.818, p=0.002); and exercise systolic blood pressure to exercise time to peak filling rate in a heart rate-independent manner, (rpartial=0.89, p<0.001). CONCLUSION: Persistent TSH suppression in LT4-treated Graves' disease patients promotes pressure dependent renin secretion, and modulates resting early LV diastolic relaxation. It is also associated with exaggerated exercise systolic blood pressure response and decreased ejection fraction response to exercise.

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Is hypertensive response in treadmill testing better identified with correction for working capacity? A study with clinical, echocardiographic and ambulatory blood pressure correlates.

Zanettini JO, Fuchs FD, Zanettini MT, Zanettini JP.

Division of Cardiology, Hospital de Clinicas de Porto Alegre, UFRGS, Brazil. ffuchs hcpa.ufrgs.br

Hypertensive response in treadmill testing is associated with the development of hypertension, but it is still unclear if it is better identified by systolic or diastolic response, and measured directly or corrected by working capacity. We investigated 75 patients with normal office blood pressure through a treadmill testing, ambulatory blood pressure (ABP) monitoring, and two-dimensional Doppler echocardiogram. Characteristics associated with systolic blood pressure (SBP) response corrected by the estimated metabolic equivalent (MET) were identified in multiple linear regression models. SBP response was associated more consistently with age, body mass index (BMI), systolic ABP and left ventricular posterior wall thickness (p < 0.001) than diastolic response in the bivariate analysis, especially when corrected by MET. Age, BMI and nightly SBP were independently associated with SBP response corrected by MET in the multivariate analysis. Individuals from the top tertile of SBP response corrected by MET (> or =11.3 mmHg/MET) were older and had higher BMI, ABP and left ventricular septal and posterior wall thickness than individuals classified in the lower tertiles. These differences were more pronounced than the differences observed between individuals with and without a peak exercise blood pressure higher than 210 mmHg. We concluded that individuals with a high blood pressure response in treadmill testing have higher BMI, left ventricular posterior wall thickness and SBP measured by ABP monitoring than individuals without such a response. These differences were stronger when the variation of blood pressure during exercise was corrected by the amount of work performed.

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Effects of crossed leg on blood pressure.

Pinar R, Sabuncu N, Oksay A.

Marmara University College of Nursing, Istanbul, Turkey. rukiyepinar yahoo.com

It is known that many factors influence an individual's blood pressure measurement. However, guidelines for accurately measuring blood pressure inconsistently specify that the patient should keep feet flat on the floor. The purpose of this study was to examine the effects of a crossed leg position on blood pressure in a Turkish sample. A prospective study of 238 subjects with an unmedicated high-normal blood pressure, stage 1 or stage 2 hypertension was conducted. After obtaining informed consent, subjects positioned their feet flat on the floor while their blood pressure was being measured. After 3 min, the blood pressure was measured again with the subject's leg crossed at the knee. Mean values of blood pressure were compared by t-test between two measurements. Statistical significance for all analysis was taken at the 5% level. The results indicated that both systolic and diastolic blood pressure increased significantly with the crossed leg position. Crossing the leg at the knee results in a significant increase in blood pressure. When blood pressure is measured, subjects should be instructed to have feet flat on the floor to eliminate a potential source of error.

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Prevalence of sustained hypertension and obesity in urban and rural school going children in Ludhiana.

Mohan B, Kumar N, Aslam N, Rangbulla A, Kumbkarni S, Sood NK, Wander GS.

Department of Cardiology, Dayanand Medical College and Hospital, Ludhiana. info hdhiheart.com

BACKGROUND: Increasing trend of hypertension is a worldwide phenomenon. The data on sustained hypertension in school going children is scanty in India. The present study was conducted to evaluate the prevalence of sustained hypertension and obesity in apparently healthy school children in rural and urban areas of Ludhiana using standard criteria. METHODS AND RESULTS: A total of 2467 apparently healthy adolescent school children aged between 11-17 years from urban area and 859 students from rural area were taken as subjects. Out of total 3326 students, 189 were found to have sustained hypertension; in urban areas prevalence of sustained hypertension was 6.69% (n=165) and in rural area it was 2.56% (n=24). Males outnumbered females in both rural and urban areas. The mean systolic and diastolic blood pressure of hypertensive population in both urban and rural population was significantly higher than systolic and diastolic blood pressure in their normotensive counterparts (urban normotensive systolic blood pressure:115.48+/-22.74 mmHg, urban hypertensive systolic blood pressure: 137.59+/-11.91 mmHg, rural normotensive systolic blood pressure: 106.31+/-19.86 mmHg, rural hypertensive systolic blood pressure: 131.63+/-10.13 mmHg, urban normotensive diastolic blood pressure: 74.18+/-17.41 mmHg, urban hypertensive diastolic blood pressure: 84.58+/-8.14 mmHg, rural normotensive diastolic blood pressure: 68.84+/-16.96 mmHg, rural hypertensive diastolic blood pressure: 79.15+/-7.41 mmHg). Overweight populationwas significantly higher in urban area. There were 287 (11.63%) overweight students and 58 (2.35%) were obese. In rural population overweight and obese students were 44 (4.7%) and 34 (3.63%) respectively. There was significant increase in prevalence of hypertension in both rural and urban population with increased body mass index in urban students; those with normal body mass index had prevalence of hypertension of 4.52% (n=96), in overweight it was 15.33% (n=44) and in obese it was 43.10% (n=25). In rural area, the overweight students showed prevalence of sustained hypertension in 6.82% (n=3) and in obese group it was 61.76% (n=21). None of the student with normal body mass index in rural area was found to be hypertensive. The mean body mass index of hypertensive population in both rural and urban areas was significantly higher than respective normotensive population (mean body mass index in urban normotensive group: 20.34+/-3.72 kg/m2, hypertensive group: 24.91+/-4.92 kg/m2; mean body mass index in rural normotensive group: 18.41+/-3.41 kg/m2, hypertensive group: 21.37+/-3.71 kg/m2, p<0.01). CONCLUSIONS: Prevalence of sustained hypertension is on the rise in urban area even in younger age groups. Blood pressure is frequently elevated in obese children as compared to lean subjects. This is possibly related to their sedentary lifestyle, altered eating habits, increased fat content of diet and decreased physical activities.

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Factors associated with poorly-controlled hypertension in continuous ambulatory peritoneal dialysis patients.

Wong PN, Mak SK, Lo KY, Tong GM, Wong AK.

Renal Unit, Department of Medicine, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong SAR, China. apnwong yahoo.com

INTRODUCTION: Hypertension is highly prevalent among continuous ambulatory peritoneal dialysis (CAPD) patients and is a major risk factor for cardiovascular complications. This study examines the risk factors associated with poorly-controlled hypertension in CAPD. METHODS: We performed a cross-sectional study of 66 stable adult CAPD patients to evaluate their hypertension control over a period of three to four months and their associations with other clinical and laboratory parameters. RESULTS: The mean age of the patients was 56.7 (plus or minus 1.27) years. Their mean systolic and diastolic blood pressure were 139 (plus or minus 2.59) mmHg and 77 (plus or minus 1.35) mmHg respectively; 71 percent of them were on antihypertensive drugs. Thirty (45.5 percent) patients had high blood pressure greater than 140/90mmHg. Compared with patients with normal blood pressure, patients with high blood pressure received significantly more antihypertensive drugs (p-value equals 0.034) and were more likely to be clinically overloaded (p-value less than 0.001). Multivariate analysis showed that systolic blood pressure was predicted by volume expansion (p-value less than 0.001) while diastolic blood pressure was negatively predicted by age (p-value equals to 0.004). In addition, volume overload was predicted positively by dialysate/plasma creatinine (p-value equals 0.011) and negatively by serum albumin (p-value less than 0.001). CONCLUSION: Clinically-apparent volume overload was associated with poor systolic blood pressure control despite aggressive antihypertensive drug therapy. This finding underlines the importance of fluid control and could provide an explanation of the poor outcome observed in patients with high peritoneal transport.

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Is carbon monoxide-mediated cyclic guanosine monophosphate production responsible for low blood pressure in neonatal respiratory distress syndrome?

van Bel F, Latour V, Vreman HJ, Wong RJ, Stevenson DK, Steendijk P, Egberts J, Krediet TG.

Department of Neonatology, Rm. KE.04.123.1, Wilhelmina Children's Hospital, University Medical Center, PO Box 85090, 3508 AB Utrecht, The Netherlands. f.vanbel wkz.azu.nl

Infant respiratory distress syndrome (RDS) involves inflammatory processes, causing an increased expression of inducible heme oxygenase with subsequent production of carbon monoxide (CO). We hypothesized that increased production of CO during RDS might be responsible for increased plasma levels of vasodilatory cGMP and, consequently, low blood pressure observed in infants with RDS. Fifty-two infants (no-RDS, n = 21; RDS, n = 31), consecutively admitted to the neonatal intensive care unit (NICU) between January and October 2003 were included. Hemoglobin-bound carbon monoxide (COHb), plasma cGMP, plasma nitric oxide (NOx), and bilirubin were determined at 0-12, 48-72, and at 168 h postnatally, with simultaneous registration of arterial blood pressure. Infants with RDS had higher levels of cGMP and COHb compared with no-RDS infants (RDS vs. no-RDS: cGMP ranging from 76 to 101 vs. 58 to 82 nmol/l; COHb ranging from 1.2 to 1.4 vs. 0.9 to 1.0%). Highest values were reached at 48-72 h [RDS vs. no-RDS mean (SD): cGMP 100 (39) vs. 82 (25) nmol/l (P < 0.001); COHb 1.38 (0.46) vs. 0.91 (0.26)% (P < 0.0001)]. Arterial blood pressure was lower and more blood pressure support was needed in RDS infants at that point of time [RDS vs. no-RDS mean (SD): mean arterial blood pressure 33 (6) vs. 42 (5) mmHg (P < 0.05)]. NOx was not different between groups and did not vary with time. Multiple linear regression analysis showed a significant correlation between cGMP and COHb, suggesting a causal relationship. Mean arterial blood pressure appeared to be primarily correlated to cGMP levels (P < 0.001). We conclude that a CO-mediated increase in cGMP causes systemic vasodilation with a consequent lower blood pressure and increased need for blood pressure support in preterm infants with RDS.

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