Non-dipper ve dipper normotansif bireylerede SCORE kardiyovasküler risk puanlama sisteminin değerlendirilmesi

Amaç: Klinik kan basıncı (KB) ölçümü ile karşılaştırıldığında 24-saatlik ambulatuar kan basıncı izlenmesi ile (AKBİ), hipertansiyon (HT) şiddeti, gün içi kan basıncının (KB) değişkenliği ve 24 saatlik terapötik etkinliği değerlendirmede belirgin avantaj elde edilmiştir. Normotansif veya komplike olmayan esansiyel HT’li birçok kimsede sistolik (SKB) ve diyastolik KB (DKB) gece uykusu sırasında en düşük seviyelere iner, en yüksek değere sabah ulaşır ve gün içinde yavaş bir azalma gösterir. KB’nin uyku süresi boyunca gündüz ölçümlerine göre % 10'dan fazla azalması sirkadiyen değişimin olduğunu gösterir. Bu günlük değişimin bulunması normal bir bulgu olan dipper KB paterni olarak tanımlanırken, olmaması ise non-dipper olarak tanımlanır. Non-dipper KB uç organ hasarı ve ölümcül - ölümcül olmayan kardiyovasküler hastalıklarla (KVH) anlamlı şekilde ilişkili olduğu gösterilmiştir. Çok sayıda AKBİ çalışmasında sadece hipertansif hastalarda değil, normotansif bireylerde de non-dipper KB uç organ hasarı ve ölümcül ve ölümcül olmayan KV olaylarla ilişkili olduğu gösterilmiştir. Kardiyovasküler (KV) olay riskinde artış bulunan bireylerde sistematik KV risk değerlendirmesi önerilir. SCORE risk sistemi, ilk ölümcül aterosklerotik olayın 10 yıllık riskini değerlendirir. Bu çalışmanın amacı normotansif bireylerde non-dipper KB ile SCORE risk sistemi arasındaki bir ilişki olup olmadığının araştırılmasıdır. Yöntemler: Bu çalışmada, normotansif olan ardışık 100 kişi prospektif olarak değerlendirildi. Bu kişilerden 52 tanesi normotansif non-dipper grubunda ve 48 tanesi normotansif dipper grubundaydı. Non-dipper ve dipper hasta grupları 24 saatlik ambulatuar kan basıncı izlemine (AKBİ) göre belirlendi. SCORE sistemine göre yaş, cinsiyet, sigara kullanımı, sistolik kan basıncı (SKB) total kolesterol (TK) ve HDL kolesterol gibi risk faktörleri kullanılarak 10 yıllık ölümcül KV olay riski hesaplandı. Bulgular: Non dipper normotansif çalışma grubunda SCORE risk sistemi anlamlı olarak yüksek saptandı (p=0.005). Ayrıca LDL ve TK değerleri non dipper HT’li hasta grubunda anlamlı olarak daha yükseti. Kreatinin klirensi ise dipper normotansif çalışma grubunda daha yüksek saptandı. Diğer demografik, klinik ve laboratuvar parametreler iki grup arasında benzerdi. AKBİ’de ise gece SKB ve DKB anlamlı olarak non-dipper normotansif çalışma grubunda yüksek saptandı (p<0.001). SCORE risk oranı ile gündüz-gece SKB değişim oranı arasında orta derecede olmasına rağmen anlamlı negatif korelasyon, gündüz-gece DKB değişim oranı ile ise zayıf ama anlamlı negatif korelasyon izlendi (r = 0.-386, p < 0.001; r = -0.294, p=0.004; sırasıyla) Sonuç: Bu çalışmada ilk defa non-dipper HT ile SCORE risk sistemi arasında önemli bir ilişki olduğu gösterilmiştir. SCORE risk sistemi ile hesaplanan 10 yıllık fatal KV olay ihtimalinin non dipper hasta grubunda daha yüksek saptanması, normotansif bireylerinde AKBİ ile takibinin önemini ortaya çıkarmıştır. Ayrıca, non-dipper HT, SCORE risk sisteminin içinde ek bir risk faktörü olması açısından değerlendirilebilir. Bunun için prospektif ve daha çok hasta üzerinde yapılan uzun dönemli takip çalışmalarına ihtiyaç vardır.

Anahtar Kelimeler:

Ambulatuar kan basıncı izleme, kardiyovasküler hastalık, non-dipper normotansif, SCORE risk sistemi

Evaluation of SCORE cardiovascular risk scoring system in non-dipper and dipper normotensive individuals.

Background: The results of 24-hour ambulatory blood pressure (AKBİ), hypertension (HT), intra-day blood pressure (KB) variability, and 24-hour therapeutic efficacy were compared with clinical blood pressure (KB). In many normotensive or uncomplicated patients with HT, systolic (SKB) and diastolic KB (DKB) are reduced to the lowest levels during night sleep, reaching the highest value in the morning and showing a slow decrease during the day. Reduction of CB by more than 10% over daytime measurements shows that circadian changes occur. The presence of this daily change is defined as the dipper KB pattern which is a normal finding. Non-dipper BP was shown to be significantly associated with organ damage and deadly non-fatal cardiovascular disease (KVH). Numerous ACBI studies have been shown to be associated with non-dipper KB end organ damage and fatal and non-fatal cardiovascular (KV) events in normotensive individuals, not only in hypertensive patients. A systematic KV risk assessment is recommended for individuals with an increased risk of KV events. The SCORE risk system assesses the 10-year risk of the first lethal atherosclerotic event. The aim of this study was to investigate whether there is a relationship between non-dipper BP and SCORE risk system in normotensive individuals.Methods: In this study, 100 consecutive patients who were normotensive were evaluated prospectively. 52 of them were in normotensive non-dipper group and 48 were in normotensive dipper group. Non-dipper and dipper patient groups were determined according to AKBİ. According to SCORE system, risk factors such as age, gender, smoking, systolic blood pressure (SKB), total cholesterol (TK) and HDL cholesterol were used to calculate the risk of 10-year fatal KV event.Results: SCORE risk system was significantly higher in the non-dipper normotensive study group (p = 0.005). LDL and TK values were significantly higher in non-dipper group. Creatinine clearance was higher in the dipper normotensive study group. Other demographic, clinical and laboratory parameters were similar between the two groups. In AKBİ, SKB and DKB were significantly higher in non-dipper normotensive study group at night (p <0.001). Although there was a moderate correlation between SCORE risk ratio and day to night SKB rate of change, there was a significant negative correlation and a negative but significant negative correlation with day and night DKB rate of change (r = 0.- 386, p <0.001; r = -0.294, p = 0.004). Conclusion: In this study, there was a significant relationship between non-dipper HT and SCORE risk system for the first time. The high probability of a 10-year fatal KV event calculated by the SCORE risk system in the non-dipper patient group revealed the importance of follow-up with AKBİ in normotensive individuals. In addition, non-dipper HT can be evaluated as an additional risk factor within the SCORE risk system. For this, long-term follow-up studies on prospective and more patients are needed.

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KAYNAKLAR
1. Murphy SJ, Coughlan CA, Tobin O, et al. Continuation and adherence rates on initially-prescribed intensive secondary prevention therapy after rapid access stroke prevention (rasp) service assessment. Journal of the neurological sciences. 2016;361:13-18
2. Seo WS, Oh HS. The circadian rhythms of blood pressure and heart rate in the hypertensive subjects: Dippers and non-dippers. Yonsei medical journal. 2002;43:320-328
3. Fujii T, Uzu T, Nishimura M, et al. Circadian rhythm of natriuresis is disturbed in nondipper type of essential hypertension. American journal of kidney diseases : the official journal of the National Kidney Foundation. 1999;33:29-35
4. Verdecchia P, Schillaci G, Gatteschi C, et al. Blunted nocturnal fall in blood pressure in hypertensive women with future cardiovascular morbid events. Circulation. 1993;88:986-992
5. Ohkubo T, Imai Y, Tsuji I, et al. Relation between nocturnal decline in blood pressure and mortality. The ohasama study. American journal of hypertension. 1997;10:1201-1207
6. Verdecchia P, Schillaci G, Guerrieri M, et al. Circadian blood pressure changes and left ventricular hypertrophy in essential hypertension. Circulation. 1990;81:528-536
7. Verdecchia P, Schillaci G, Porcellati C. Dippers versus non-dippers. Journal of hypertension. Supplement : official journal of the International Society of Hypertension. 1991;9:S42-44
8. Hermida RC, Ayala DE, Mojon A, et al. Decreasing sleep-time blood pressure determined by ambulatory monitoring reduces cardiovascular risk. J Am Coll Cardiol. 2011;58:1165-1173
9. Piepoli MF, Hoes AW, Agewall S, et al. 2016 european guidelines on cardiovascular disease prevention in clinical practice: The sixth joint task force of the european society of cardiology and other societies on cardiovascular disease prevention in clinical practice (constituted by representatives of 10 societies and by invited experts)developed with the special contribution of the european association for cardiovascular prevention & rehabilitation (eacpr). European heart journal. 2016;37:2315-2381
10. Mancia G, Fagard R, Narkiewicz K, et al. 2013 esh/esc guidelines for the management of arterial hypertension: The task force for the management of arterial hypertension of the european society of hypertension (esh) and of the european society of cardiology (esc). Journal of hypertension. 2013;31:1281-1357
11. Levey AS, Bosch JP, Lewis JB, et al. A more accurate method to estimate glomerular filtration rate from serum creatinine: A new prediction equation. Modification of diet in renal disease study group. Annals of internal medicine. 1999;130:461-470
12. Pickering TG. The clinical significance of diurnal blood pressure variations. Dippers and nondippers. Circulation. 1990;81:700-702
13. Verdecchia P, Porcellati C, Schillaci G, et al. Ambulatory blood pressure. An independent predictor of prognosis in essential hypertension. Hypertension (Dallas, Tex. : 1979). 1994;24:793-801
14. Wei FF, Li Y, Zhang L, et al. Association of target organ damage with 24-hour systolic and diastolic blood pressure levels and hypertension subtypes in untreated chinese. Hypertension (Dallas, Tex. : 1979). 2014;63:222-228
15. Portaluppi F, Tiseo R, Smolensky MH, et al. Circadian rhythms and cardiovascular health. Sleep medicine reviews. 2012;16:151-166
16. de la Sierra A, Redon J, Banegas JR, et al. Prevalence and factors associated with circadian blood pressure patterns in hypertensive patients. Hypertension (Dallas, Tex. : 1979). 2009;53:466-472
17. Güngör A, Aydın, Y , Celbek, G , Başar, C , Alemdar, R , Ordu, S , Yıldırım, H , Özhan, H . Dipper ve nondipper hipertansiyon hastalarında asimetrik dimetil arjinin düzeyleri. Dicle Tıp Dergisi.37 / 4 (Mart 2015): 332-338.
18. Hermida RC, Smolensky MH, Ayala DE, et al. [2013 ambulatory blood pressure monitoring recommendations for the diagnosis of adult hypertension, assessment of cardiovascular and other hypertension-associated risk, and attainment of therapeutic goals (summary). Joint recommendations from the international society for chronobiology (isc), american association of medical chronobiology and chronotherapeutics (aamcc), spanish society of applied chronobiology, chronotherapy, and vascular risk (secac), spanish society of atherosclerosis (sea), and romanian society of internal medicine (rsim)]. Clinica e investigacion en arteriosclerosis : publicacion oficial de la Sociedad Espanola de Arteriosclerosis. 2013;25:74-82
19. Emilia Rymkiewicz AUAR-WAUKB-SAUGD. Coexistence of non-dipper hypertension with other chronic diseases. 2015:84-87-84-87
20. A. L. Evidence of impaired night-response of blood pressure in hypertensive smokers. An update. J Cardiol Curr Res. 2015;4(2): 00138.