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

Yıl 2018, , 6 - 10, 25.12.2018

Mevlüt Serdar Kuyumcu , Fatih Öksüz

https://doi.org/10.22312/sdusbed.470132

Öz

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.

Öz

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.

Kaynakça

• 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.