Masaryk University • Faculty of Medicine • Brno • Czech Republic NONINVASIVE METHODS IN CARDIOLOGY 2016 Edited by: Kenner T., Cornelissen G., Siegelova J., Dobsak P. Brno 2016 Under the auspices of doc. PhDr. Mikuláš Bek, Ph.D., Rector of Masaryk University Brno prof. MUDr. Jiří Mayer, CSc, Dean of Faculty of Medicine Masaryk University Brno Reviewed by: Prof. MUDr. Kamil Javorka, DrSc. Jessenius Faculty of Medicine in Martin Comenius University in Bratislava Slovak Republic © 2016 Masarykova univerzita ISBN 978-80-210-8391-2 Contents History of International Scientific Cooperation Among Masaryk University and University of Minnesota, University of Graz and University of Paris........................................................................5 Prof. Mudr. Jarmila Siegelová, DrSc. Time Structure of Blood Pressure and Aging: the Brno Database.....................................................19 Germaine Cornelissen, Jarmila Siegelová, Alena Havelkova, Leona Dunklerova, Jiri Dušek, Larry Beaty, Kuniaki Otsuka Lessons Learned from Worldwide Chronobiologically-Interpreted Blood Pressure Monitoring.......33 Germaine Cornelissen, Kuniaki Otsuka, Jarmila Siegelová, Jiri Dušek, Alena Havelkova, RK Singh, RB Singh, Alain Delcourt, Lyazzat Gumarova, Yoshihiko Watanabe, Larry Beaty Three Hypertensive Patients' Ambulatory Blood Pressure Reduced by Acupressure........................41 Yoshihiko Watanabe, Franz Halberg, Hiroshi Sakura, Germaine Cornelissen Changes with Age in the Circadian Rhythm of Circulating Melatonin..............................................49 Cathy Lee Gierke, Roberto Tarquini, Federico Perfetto, Jarmila Siegelová, Germaine Cornelissen Seven Day /24 h Ambulatory Blood Pressure Monitoring: Circadian Variability of Pulse Pressure . 59 Jarmila Siegelová, Jiří Dušek, Alena Havelková, Michal Pohanka, Leona Dunklerová, Petr Dobšák, Germaine Cornelissen Cardio-Ankle Vascular Index (CAVI) for Arterial Stiffness - Theory and Significance -................73 Kozaburo Hayashi Effects of Exercise Training on Arterial Stiffness in Patients with Ischemic Coronary Artery Disease............................................................................................81 Alena Havelková, Leona Mífková, Petra Palanová, Veronika Mrkvicová, Michaela Spáčilová, Jiří Jančík, František Várnay, Jiří Jarkovský, Ladislav Dušek, Michaela Sosíková, Pavel Vank, Jarmila Siegelová, Petr Dobšák Basic Concepts and Importance of Renal Rehabilitation...................................................................91 Palanová P., Mrkvicová V., Pernicová M., Brychtová S., Reichertová A., Nedbálková M., Svojanovský J., Sosíková M., Siegelová J., Souček M., Dobšák P. The Use of MOTOmed in Subacute Phase of Rehabilitation after Total Knee Arthroplasty.............97 Mrkvicová V., Palanová P., Lofajová B., Siegelová J., Sosíková M., Dobšák P. Department of Physiology, Faculty of Medicine, Masaryk University Brno: History and Contemporary Scientific Projects....................................................................................................103 Doc. PharmDr. Petr Babula, Ph.D., Prof. MUDr. Marie Nováková, Ph.D. Left Atrial Strain Is Highly Predictive of Pulmonary Artery Pressures in Patients with Severe Aortic Stenosis..............................................................................................................105 Jean-Christophe Eicher, AJobila Valentin Yameogo, Ludwig Serge Aho, Jean-Luc Philip, Gabriel Laurent, Petr Dobšák Vascular Function in Health and Disease: A Gender Comparative Study.........................................113 Irhad Trozic, Dieter Platzer, Nandu Goswami Variabilität in der Blutdruckmessung................................................................................................117 Prof. Mudr. Jarmila Siegelová, DrSc. NONINVASIVE METHODS IN CARDIOLOGY 2016 History of International Scientific Cooperation among Masaryk University and University of Minnesota, University of Graz and University of Paris Prof. MUDr. Jarmila Siegelova, DrSc. Department of Physiotherapy and Rehabilitation, Department of Sports Medicine and Rehabilitation, St. Anne's University Hospital, Masaryk University Brno, Czech Republic Cooperation with University of Minnesota Cooperation with Professor Franz Halberg and with professor Germaine Cornélissen, Dr. Othild Schwartzkopff Halberg Chronobiology Center of the University of Minnesota, USA started in 1988 and with Brno team - professor Bohumil Fišer, Jiří Dušek, M.D. and professor Jarmila Siegelová. The common studies of circadian variability of cardiovascular variables and baroreflex sensitivity were published in many papers as the result of this common work and our Brno team participated on international projects Womb to Tomb, later BIOCOS, under the direction from Halberg Chronobiology Center from Minnesota. Figure 1: Franz Halberg, M.D., Dr. h.c. (Montpellier), Dr. h.c. (Ferrara), Dr. h.c. (Tyumen), Dr. h.c. (Brno), Dr. h.c. (L'Aquila), Dr. h.c. (People's Friendship University of Russia, Moscow), Professor of Laboratory Medicine and Pathology, Physiology, Biology, Bioengineering and Oral medicine (* 5. 6. 1919 - f 9. 6. 2013) Cooperation with University Graz The international cooperation continued with Professor Thomas Kenner, from the Department of Physiology in University in Graz (Austria), where the original studies of heart rate variability, baroreflex sensitivity and chronobiology have been realized and included in the common international project of analysis of cardiovascular control in physiology and pathophysiology. 5 NONINVASIVE METHODS IN CARDIOLOGY 2016 Figure 2: Prof. Dr. Thomas Kenner, M.D., Dr. h.c. mult. Dr. h. c. Universität Jena, 1990 Dr. h. c, Semmelweis University Budapest, 1998 Dr. h. c, Masaryk University Brno, 2000 Cooperation with University of Paris The international cooperation continued with Professor Jean-Paul Martineaud and Professor Dr. Etienne Savin, Medical Faculty, Lariboisiere Hospital, University of Paris (France) and was very intensively developed. There are the common original studies of aortic compliance and blood flow regulation in cerebral arteries, baroreflex sensitivity in healthy subjects and patients with essential hypertension. Figure 3: Prof. Jean Paul Martineaud, M.D. (*27.3.1931 - f29.11.2010) 6 NONINVASIVE METHODS IN CARDIOLOGY 2016 Prof. MUDr. Jan Penäz, CSc. from Masaryk University, Faculty of Medicine, Department of Physiology will be remembered foremost as an exceptional physiologists who focused primarily on cardiovascular physiology He studied cardiovascular reflexes and control of blood pressure in animal studies and in men. One of the main discovery of Prof. Penäz was volume-clamp method of noninvasive blood pressure measurement beat by beat. One of the common meetings was organized in 1996 at the occasion of Professor Penäz birthday. 7 NONINVASIVE METHODS IN CARDIOLOGY 2016 Medical Faculty • Masaryk University • Brno » Czech Republic PROCEEDINGS SYMPOSIUM CARDIOVASCULAR COORDINATION IN HEALTH AND BLOOD PRESSURE DISORDERS Dedicated to the Seventieth Anniversary of Professor Jan Peň a/. Edited by: F. HALBERG, T. KENNER, H. FIŠER, J. S1EGELOVÁ Figure 5: Proceedings from Symphosium 1996 in Masaryk University 8 NONINVASIVE METHODS IN CARDIOLOGY 2016 One Symposium of international scientific cooperation among Masaryk University and University of Minnesota, University of Graz and University of Paris was dedicated to the Seventieth Anniversary or Professor Jan Peňáz. Professor Pavel Bravený, M.D., Ph.D., Vice-rector Masaryk University in 1996, described the whole scientific career of Jan Peňáz and his international recognition. Professor Franz Halberg, M.D., d. h. c. mult., gave the lecture Circadiani, circaseptani, circasemiseptanique in chonomis seclusorum, praematurorum, seniumque: in honorem Johannis Penazenis modo Mendeliano, Goedeliano, Keplerianoque. This part of the world (Brno) is not only a seat of genetics, mathematics and astronomy, but it is home to pioneering in physiological monitoring: the home of school of Jan Penaz. Professor Germaine Cornélissen and others presented Current limitations and promise of ambulatory blood pressure monitoring. She concluded that the pioneering contributions of Dr. Jan Penaz including his development of a BP measurement technique are a major step forward towards a chonobiologic assessment of the risk of vascular disease. Professor Thomas Kenner, M.D., d. h. c. mult., remembered in presentation One hundred years since Riva-Rocci's invention of the cuff-technique. He also mentioned his first personal experience with indirect blood pressure measurement in 1959. Professor Jarmila Siegelová, Professor Bohumil Fišer, Dr. Mohamed Al-Kubati, Dr. Jiří Dušek together with team from Minnesota presented Barorefelex heart rate sensitivity in hypertensives: the role of antihypertensive therapy. Professor Etienne Savin, Professor Jean Paul Martineaud and Dr. Philipe Bonnin together with Prof. Siegelová and Prof. Fišer presented common results Noninvasive measurement of blood velocity in middle cerebral artery at rest and during abrupt decrease of blood pressure in man. Professor Bohumil Fišer and other presented The noninvasive estimation of the gain of the arterial baroreceptor reflexes in man. Professor Nataša Honzíkova, Professor Bořivoj Semrád, Professor Bohumil Fišer and Dr. Růžena Lábrová presented Correlation between non-invasively determined barorefelex sensitivity, heart rate variability and mortality in patients after myocardial infarction. All presented lectures were connected with the blood pressure measurement, also beat by beat measurement of blood pressure based on volume clamp method of Professor Peňáz. 9 NONINVASIVE METHODS IN CARDIOLOGY 2016 Figuře 7: Professor Franz Halberg, Professor Pavel Bravený, Brigitte Kenner, Professor Thomas Kenner, Professor Jarmila Siegelová, Professor Jan Peňáz, Professor Bohumil Fišer in 1996 10 NONINVASIVE METHODS IN CARDIOLOGY 2016 Figure 8: Professor Jarmila Siegelovd, Professor Jan Pendz,, Professor Bohumil Fiser in 1996 There are further examples of other scientific activities of the cooperation between University of Minnesota, USA, University of Graz, Austria, University of Paris and Masaryk University. Figure 8: Professor Franz Halberg, Brno International Congress MEFA 2005 11 NONINVASIVE METHODS IN CARDIOLOGY 2016 Figure 10: Dr. Jiří Dušek, Professor Franz, Halberg, Dr. Othild Schwartzkopff, Professor Thomas Kenner, Brno International Congress MEFA 2005 Figure 11: Professor Germaine Cornelissen, Brno Congress Noninvasive Methods in Cardiology 2003 12 NONINVASIVE METHODS IN CARDIOLOGY 2016 NONINVASIVE METHODS IN CARDIOLOGY 2016 Figure 14: Professor Thomas Kenner, Brigitte Kenner, Professor Jarmila Siegelovd, Professor Jean-Paul Martienaud, Brno International Congress MEFA 2003 Figure 15: Professor Bohumil Fišer, As. Professor Michal Pohanka, Professor Thomas Kenner, Brigitte Kenner, Dr. Othild Schwartzkopff, Professor Franz Halberg, Dr. Jiří Dušek, Professor Jarmila Siegelovd, Brno Congress Noninvasive Methods in Cardiology 2008 (Brno Consensus) Chronobiology, studied by Franz Halberg, showed broad spectrum of rhythms in us and around us; they are being marched up by the dozens but have not yet been recognized in terms of their pertinence to everyday life. We feel honored to have had the possibility of cooperation with Prof. Halberg since 1980s. Chronobiologically interpreted blood pressure and heart rate monitoring detects prehypertension, prediabetes and a premetabolic syndrome in vascular variability disorders, that interact with a reliably diagnosed MESOR hypertension that can carry a risk greater than a high blood pressure and that can 14 NONINVASIVE METHODS IN CARDIOLOGY 2016 coexist to form vascular variability syndromes, unrecognized in a conventional health care, but some of them already treatable. Figure 16: Professor Franz Halberg, Dr. Othild Schwartzkopff Professor Germaine Cornélissen in Halberg Chronobiolgy Center University Minnesota on May 3-4, 2013 during Symposium (videoconference) in Masaryk University Brno In 2008 during Congress of Noninvasive methods in cardiology this Brno Consensus on vascular variability disorders and vascular variability syndromes was presented. It was published as Halberg et al. Extended consensus on means and need to detect vascular variability disorders and vascular variability syndrome. In World Heart J 2010;2,4:297-305 and World Heart J 2011;3,l:63-77. Prof Halberg suffered by the fact, that his ideas overrun the development of science for tens of years. A lot of lectures from Prof. Halberg, Prof. Kenner, former president of University of Graz, Austria, Prof. Cornelissen, Prof. Fišer, Dr. Dušek, prof. Siegelová were presented at international scientific conferences, hold every year in Brno and published. 15 NONINVASIVE METHODS IN CARDIOLOGY 2016 tiolutmil Fishr I. MESOR-HypartariBlon OOdO 34DS 0M0 1UB llfO 10 00 DUD 0900 04:00 DB40I 11:90 10£fl 1040 OOflD 00300 04300 00» 1190 11300 BtOO DO SO DO 20 HAD 13» 1COO DO 90 0I:H 1H9 V. Excanhm Pulaa Prusu ra VI. Daficient Tlma [clock hours) Figure 17: Brno Consensus on vascular variability disorders and vascular variability syndromes Prof. Petr Dobšák add the cooperation with Bourgond University, Dijon, France with Prof. Jean Eric Wolf and Dr. Jean Chritoph Eicher and Tohoku University, Sendai, Japan, Prof. Masario Kohzuki and Prof. Tomoyuki Yambe. 30 years until now the chronobiological data measured in Czech population in Brno were immediately analyzed by Prof. Germaine Cornelissen and the results of these analyses served not only for scientific work, but also for therapy. Between the years 2000 and 2008 the Brno team consisting of Prof. Fišer, Dr. Dušek and me collected 73 888 sets of blood pressure and heart rate measurements and all data were in the following day analyzed by Prof. G. Cornelissen. The daily data exchange and analysis continues until now. 16 NONINVASIVE METHODS IN CARDIOLOGY 2016 Prof. Germaine Cornelissen presented and still presents with her team from Halberg Chronobiology center Minnesota lot of publications for congresses and symposia in Brno as is documented in every year publications of Noninvasive methods of cardiology. We hope that we will continue the cooperation between Halberg Chronobiology Center and Professor Germaine Cornelissen to finish the international scientific projects as BIOCOS and with Professor Thomas Kenner from University of Graz, Austria and his team and other foreign centers from France and Japan. We will also implement ideas of science in the foot steps of the great scientists, who left us Professor Halberg, Professor Peňáz, Professor Martineaud, Professor Semrád and Professor Fišer. References http://www.med.muni.cz/index.php?id=1376 1. Halberg F, Kenner T, Fiser B, Siegelova J(eds): Cardiovascular Coordination in Health and Blood Pressure Disorders. Faculty of Medicine, Masaryk University, Brno (1996). 2. Halberg F, Kenner T, Fiser B, Siegelova J(eds): Chronobiology and non-invasive methods in cardiology. Brno : IDV PZ, MU, 1999. ISBN 80-7013-279-5.Faculty of Medicine, Masaryk University, Brno (1999). 3. Halberg F, Kenner T, Fiser B (eds): The importance of chronobiology in diagnosis and therapy of internal diseases. Faculty of Medicine, Masaryk University, Brno (2002) 4. Halberg F, Kenner T, Siegelova J (eds): The importance of chronobiology in diagnosis and therapy of internal diseases. Faculty of Medicine, Masaryk University, Brno (2003) 5. Cornelissen G, Kenner T, Fiser B, Siegelova J (eds): Chronobiology in medicine. Faculty of Medicine, Masaryk University, Brno (2004) 6. Halberg F, Kenner T, Fiser B, Siegelova J (eds): Nonivasive methods in cardiology 2006. Faculty of Medicine, Masaryk University, Brno (2006) 7. Halberg F, Kenner T, Fiser B, Siegelova J(eds): Nonivasive methods in cardiology 2007. Faculty of Medicine, Masaryk University, Brno (2007) 8. Halberg F, Kenner T, Fiser B, Siegelova J (eds): Nonivasive methods in cardiology 2008 Faculty of Medicine, Masaryk University, Brno (2008) 9. Halberg F, Kenner T, Fiser B, Siegelova J (eds): Nonivasive methods in cardiology 2009 Faculty of Medicine, Masaryk University, Brno (2009) 10. Halberg F, Kenner T, Fiser B, Siegelova J(eds): Nonivasive methods in cardiology 2010; Faculty of Medicine, Masaryk University, Brno (2010) 11. Halberg F, Kenner T, Siegelova J (eds): Nonivasive methods in cardiology 2011; Faculty of Medicine, Masaryk University, Brno (2011) 12. Halberg F, Kenner T, Siegelova J (eds): Nonivasive methods in cardiology 2012; Faculty of Medicine, Masaryk University, Brno (2012) 13. Kenner T, Cornéllissen G, Siegelova J, Došák P (eds): Nonivasive methods in cardiology 2013; Faculty of Medicine, Masaryk University, Brno (2013) 17 NONINVASIVE METHODS IN CARDIOLOGY 2016 14. Kenner T, Cornéllissen G, Siegelova J, Dosák P (eds): Nonivasive methods in cardiology 2014; Faculty of Medicine, Masaryk University, Brno (2014) 15. Kenner T, Cornéllissen G, Siegelova J, Dosák P (eds): Nonivasive methods in cardiology 2015; Faculty of Medicine, Masaryk University, Brno (2015) 18 NONINVASIVE METHODS IN CARDIOLOGY 2016 Time Structure of Blood Pressure and Aging: the Brno Database Germaine Cornelissen1, Jarmila Siegelova2, Alena Havelkova2, Leona Dunklerova2, Jiri Dusek2, Larry Beaty1, Kuniaki Otsuka3 'Halberg Chronobiology Center, University of Minnesota, Minneapolis, MN, USA, 2Masaryk University, Brno, Czech Republic 3Tokyo Women's Medical University, Daini Hospital, Tokyo, Japan Dedicated to the memory of Franz Halberg. Abstract The circadian system tends to weaken with advancing age. The circadian amplitude of many physiological variables is reduced and the circadian acrophase becomes more labile, often occurring earlier in older people. The Brno database consists of 297 7-day/24-hour records from men (N=219) and women (N=78), 20-84 years of age, obtained by ambulatory blood pressure monitoring between January 2000 and June 2011. Subjects resided in Brno, Czech Republic, and were mostly clinically healthy at the time of monitoring. All but 23 records covered a week. Data from the 274 complete records were analyzed by the extended cosinor. Least squares spectra were computed in the frequency range from 1 cycle per week to 7 cycles per day. Population-mean cosinor spectra were obtained to assess the infradian-to-circadian (frequencies of 1 to 7 cycles per week) and circadian-to-ultradian (frequencies between 1 and 7 cycles per day) spectral domains. The circadian period was estimated by the nonlinear fit of a cosine curve with a trial period of 24 hours. With increasing age, the circadian amplitude of blood pressure was reduced and the circadian acrophase of blood pressure was advanced. In men, but not in women, the circadian period of blood pressure shortened with age. It deviated from 24 hours in over 10% of the population. There was also a transposition of the variance from the circadian to both the infradian and ultradian domains. The weakening of the circadian system was also apparent from a widening of the 95% confidence intervals of the relative amplitude, acrophase, and period. These results provide further evidence for the need to refine reference standards by accounting for changes with age in circadian (and other) rhythm characteristics. Keywords: Aging, Blood pressure, Circadian, Heart rate, Infradian, Ultradian, Variance transposition. Introduction As many other variables [1], blood pressure and heart rate have a decreased circadian amplitude in older individuals [2]. With increasing age, disease risk and incidence of morbid events also increase. In order to differentiate between an increased disease risk and natural aging, it is necessary to derive reference values as refined as possible by accounting for predictable variability in health. 19 NONINVASIVE METHODS IN CARDIOLOGY 2016 One source of predictable variation consists of the usually very prominent circadian variation. Other components, such as the week and half-week observed in physiology [3] and pathology [4] are also periodic. The circadian waveform also undergoes predictable changes as a function of age, which can be assessed by the harmonic content. Changes with age in the circadian waveform of blood pressure involve an increase in nightly values and a deepening of the postprandial dip in the early afternoon, accentuating the contribution of a 12-hour component to the circadian waveform [2, 5]. Changes with age in the time structure of blood pressure and heart rate are examined herein in the Brno database, consisting of 7-day/24-hour records obtained by ambulatory monitoring from mostly clinically healthy men and women [6-8]. It represents a homogeneous population, which lends itself well to assess changes in blood pressure and heart rate in a relatively wide frequency range spanning from one cycle per week to 7 cycles per day. Information can thus be obtained regarding variability from one day to another as well as variability accounting for changes in the circadian waveform. Subjects and Methods Blood pressure and heart rate from mostly clinically healthy men and women, 20-84 years of age, were measured around the clock, mostly at 30-minute intervals for 7 days in Brno, Czech Republic, using the TM-2421 device from A&D (Tokyo, Japan), as outlined previously [8]. Between January 2000 and June 2011, 297 records (78 from women and 219 from men) were obtained. Of those, 23 were incomplete and were not used in this investigation. Oscillometric measurements from the remaining 274 records are analyzed. The study was approved by the Ethics committee of Masaryk University. The study was explained to the subjects before they gave written, informed consent. Each data series was analyzed by the extended cosinor [9-11]. Specifically, least squares spectra were computed in the range of 1 to 7 cycles per week to assess the infradian-to-circadian time structure, and in the range of 1 to 7 cycles per day to assess the circadian-to-ultradian time structure. In addition to the MESOR (Midline Estimating Statistic Of Rhythm, a rhythm-adjusted mean value, usually more precise and more accurate than the arithmetic mean), estimates of the amplitude (half the predictable extent of change within a cycle) and of the acrophase (measure of the timing of overall high values recurring in each cycle) were obtained at each trial period. The circadian period was estimated by the nonlinear fit of a cosine curve with a trial period of 24 hours, using Marquardt's algorithm [12]. Circadian rhythm characteristics and their 95% confidence intervals were linearly regressed as a function of age, separately for men and women. Linear regression analyses also considered a quadratic model as a function of age, as well as the combined effects of age and body mass index (BMI), Population-mean cosinor spectra were computed for subjects classified in 7 age groups: younger than 25 years (Group A; 19 records), 25-34 years (Group B; 25 records), 35-44 years (Group C; 33 records), 45-54 years (Group D; 80 records), 55-64 years (Group E; 78 records), 65-74 years (Group F; 32 records), and 75 years or older (Group G; 7 records). Groups A and B and Groups F and G were pooled for some analyses in view of their smaller sample sizes. Phase-unweighted amplitude spectra were also obtained, and amplitude ratios were computed to compare the circaseptan (about-weekly) and circasemiseptan (about-half-weekly) amplitudes with the corresponding circadian amplitude. Log1Q-transformed amplitude ratios were compared among the different age groups by one-way analysis of variance (ANOVA). P-values below 0.05 are considered to indicate statistical significance. 20 NONINVASIVE METHODS IN CARDIOLOGY 2016 Results A circadian rhythm was detected with statistical significance in the large majority of individual records. On a population basis, it was invariably statistically significant (P<0.001) in each age group, Table 1. It can be seen that the MESOR of systolic blood pressure increases with advancing age from 123.4 ± 1.3 mmHg in subjects younger than 35 years of age to 129.5 ± 1.5 mmHg in subjects 65 years of age and older (P<0.05). The MESOR of diastolic blood pressure also changes as a function of age but does not show a steady increase with age. Instead, it increases until mid-adulthood from 73.8 ± 1.0 to 81.2 ± 0.8, when it reaches a maximum to drop to 77.2 ± 1.5 mmHg in the oldest age group (P<0.001). These trends with age are also documented by linear regression, as illustrated in Figures 1 and 2. The circadian amplitude of blood pressure of subjects 55 years and older is also much smaller than that of younger subjects (P<0.001), and their circadian acrophase occurs about 1 hour earlier, Table 1 and Figures 3 and 4. In the case of heart rate, the MESOR increases slightly until mid-adulthood from 69.1 ± 1.2 to 72.6 ± 0.9 beats/min, then decreases sharply to 64.8 ± 1.6 beats/min in the oldest age group (P<0.001) and the circadian amplitude decreases with advancing age (P<0.001), Table 1 and Figures 5 and 6. The weekly and half-weekly components are also detected with statistical significance. Their amplitude is larger in mid-adulthood than at younger or older ages (P<0.05). The circaseptan-to-circadian amplitude ratio of systolic blood pressure increases with age from 25.2% in subjects younger than 35 years to 49.1% in subjects 65 years and older (1-way ANOVA: F=5.281, P<0.001). Similar results are found for the circasemiseptan-to-circadian amplitude ratio of systolic blood pressure, which increases from 20.4% to 41.8% (F=4.501, P=0.002). With advancing age, there is transposition of the variance from the circadian domain to both the infradian and ultradian domains, as illustrated for systolic blood pressure in Figures 7 and 8, respectively. This is particularly the case for blood pressure. Whereas the circadian component remains the most prominent one in all age groups, its amplitude progressively decreases with advancing age. With advancing age, as the circadian amplitude decreases, the circadian period is more likely to deviate from 24 hours, and the width of its 95% confidence interval increases, Figure 9. The increased uncertainty in the estimation of the period is statistically significant, except for women's heart rate (Men: SBP, r=0.242, P<0.001; DBP, r=0.209, P=0.002; HR, r=0.186, P=0.006; Women: SBP, r=0.389, P<0.001; DBP, r=0.452, P<0.001; HR, r=0.134, NS). The width of the 95% confidence interval of the circadian acrophase also increases with age (Men: SBP, r=0.268, P<0.001; DBP, r=0.242, P<0.001; HR, r=0.200, P=0.003; Women: SBP, r=0.408, P<0.001; DBP, r=0.456, P<0.001; HR, r=0.147, NS), Figure 10. So does that of the circadian amplitude when it is expressed relative to the amplitude (in order to compensate for the marked decrease in circadian amplitude as a function of age), Figure 10 (Men: SBP, r=0.288, P<0.001; DBP, r=0.266, P<0.001; HR, r=0.201, P=0.003; Women: SBP, r=0.425, P<0.001; DBP, r=0.477, P<0.001; HR, r=0.141, NS). Discussion and Conclusion A variance transposition from circadians to neighboring extra-circadians has been reported earlier, both in terms of infradians [17] and ultradians [17, 18]. In an earlier investigation [17], 72 participants 12-106 years of age provided a 7-day record of blood pressure measured indirectly with an ambulatory monitor, mostly at 15-60-minute intervals. Amplitudes in least squares spectra at frequencies of 1 to 7 cycles per week and 1 to 8 cycles per day were analyzed by a two-way analysis of variance for subjects 21 NONINVASIVE METHODS IN CARDIOLOGY 2016 classified in four age groups (12-39, 40-59, 60-74, and >75 years of age). The decreasing circadian blood pressure amplitude with age was accompanied by an increase in the amplitude of infradian and ultradian components. The day-to-day variability in circadian characteristics was also found to increase with age [17]. In another study [18], 180 clinically healthy adults monitored their blood pressure automatically, mostly at 15-minute intervals, for 24 hours. They were assigned to three age groups (20-49, 40-60, and >60 years of age). Amplitudes in least squares spectra at frequencies of 1 to 14 cycles per day were analyzed by 2-way analysis of variance after being expressed as a percentage of the 24-hour amplitude and log10-transformed. The harmonic content was found to increase with advancing age in both men and women [18]. The circadian-to-ultradian variance transposition is readily seen in a comparison of blood pressure records from centenarians (N=ll) and medical students (N=64), Figures 6A-C, where the different behavior of blood pressure and heart rate can also be observed [19]. Older populations are more likely to take medications, including anti-hypertensive drugs, and to be less active. As noted above, circadian rhythms have been shown to persist in the absence of physical activity [3, 4]. Depending on the kind, dose and timing of daily administration of anti-hypertensive treatment, the circadian amplitude of blood pressure may be increased or decreased [20]. The effect of salt intake on the circadian rhythm of blood pressure, reviewed elsewhere [21], also depends on its relative distribution among the three daily meals [22]. Admittedly, physical activity, medications, diet, as well as emotions all affect blood pressure [23]. These confounding factors make it difficult to distinguish between healthy aging and the presence of overt disease or elevated disease risk. It is the more critical to derive time-specified reference values in health to make that distinction. The reduced amplitude and earlier acrophase of the circadian blood pressure rhythm reported herein are, however, general features of senescence, also seen in other variables [2], in clinical studies as well as in the experimental laboratory [24]. The similarity of circadian rhythm alterations observed with increasing age and after bilateral lesioning of the suprachiasmatic nuclei was noted by Franz Halberg, who suggested their involvement as a mechanism underlying changes with age [25]. In view of the prominent circadian variation in blood pressure and heart rate observed at all ages, it is recommended to take measurements around the clock for an assessment of the circadian rhythm characteristics. This is the more important that several outcome studies have shown that alterations in circadian rhythm characteristics of blood pressure and/or heart rate are associated with cardiovascular disease risk beyond the risk contributed by an elevated blood pressure [26]. For a more reliable estimation of circadian rhythm characteristics, it is recommended to monitor blood pressure around the clock for more than a single 24-hour span, preferably for at least one week at the outset [27], to examine the extent of day-to-day variability in circadian parameters [28, 29] and to obtain an estimate of the circaseptan and circasemiseptan rhythm characteristics. These components may indeed provide valuable information in their own right [30]. In view of the marked changes in the time structure of blood pressure and heart rate as a function of age, as illustrated herein, it is also mandatory to further qualify the time-specified reference values by age (as well as by gender and ethnicity). Doing so led to the definition of vascular variability disorders [20, 21] which have been shown to correlate with an increased cardiovascular disease risk [20]. With the availability of ambulatory monitors to automatically measure blood pressure around the clock for a week or longer, the availability of chronobiologic methods for the analysis of the data thus collected, and the availability of time-specified reference values qualified by gender and age in clinical health for a chronobiologic interpretation of the results, the time is ripe to bring this technology to the clinic for routine patient care. 22 NONINVASIVE METHODS IN CARDIOLOGY 2016 References 1. Nelson W, Bingham C, Haus E, Lakatua DJ, Kawasaki T, Halberg F. Rhythm-adjusted age effects in a concomitant study of twelve hormones in blood plasma of women. J Gerontol 1980; 35: 512-519. 2. Cornelissen G, Haus E, Halberg F. Chronobiologic blood pressure assessment from womb to tomb. In: Touitou Y, Haus E (Eds.) Biological Rhythms in Clinical and Laboratory Medicine. Berlin: Springer-Verlag; 1992. pp. 428-452. 3. Halberg F. Historical encounters between geophysics and biomedicine leading to the Cornelissen-series and chronoastrobiology. In: Schröder W (Ed.) Long- and Short-Term Variability in Sun's History and Global Change. Bremen: Science Edition; 2000. pp. 271-301. 4. Cornelissen G, Breus TK, Bingham C, Zaslavskaya R, Varshitsky M, Mirsky B, Teibloom M, Tarquini B, Bakken E, Halberg F, International Womb-to-Tomb Chronome Initiative Group: Beyond circadian chronorisk: worldwide circaseptan-circasemiseptan patterns of myocardial infarctions, other vascular events, and emergencies. Chronobiologia 1993; 20: 87-115. 5. Cornelissen G, Halberg F, Otsuka K, Singh RB. Separate cardiovascular disease risks: circadian hyper-amplitude-tension (CHAT) and an elevated pulse pressure. World Heart J 2008; 1 (3): 223-232. 6. Cornelissen G, Siegelova J, Havelkova A, Dunklerova L, Dusek J. Changes with age in the time structure of blood pressure. World Heart J 2016; 8(2): 141-156. 7. Cornelissen G, Otsuka K, Watanabe Y, Lee Gierke C, Beaty L, Havelkova A, Dusek J, Siegelova J. Why 7-day/24-hour ambulatory blood pressure monitoring? Day-to-day variability in blood pressure and the novelty effect. In: Kenner T, Cornelissen G, Siegelova J, Dobsak P (Eds.) Noninvasive Methods in Cardiology 2015, Brno, 19 October 2015. Brno: Masaryk University; 2015. pp. 9-18 8. Siegelova J, Dusek J, Homolka P, Vank P, Vlcek J, Cornelissen G, Halberg F. The relationship between age and circadian blood pressure variation. In: Cornelissen G, Kenner R, Fiser B, Siegelova J (Eds.) Proceedings, Symposium: Chronobiology in Medicine. Brno: Masaryk University; 2004. pp. 110-116. 9. Halberg F. Chronobiology: methodological problems. Acta med rom 1980; 18: 399-440. 10. Refinetti R, Cornelissen G, Halberg F. Procedures for numerical analysis of circadian rhythms. Biological Rhythm Research 2007; 38 (4): 275-325. 11. Cornelissen G. Cosinor-based rhythmometry. Theoretical Biology and Medical Modelling 2014; 11: 16. 24 pp. 12. Marquardt DW. An algorithm for least-squares estimation of nonlinear parameters. Journal of the Society of Industrial and Applied Mathematics 1963; 11: 431-441. 13. Gubin D, Cornelissen G, Halberg F, Gubin GD, Turti T, Syutkina EV, Grigoriev AE, Mitish MD, Yatsyk GV, Ikonomov O, Stoynev A, Madjirova N, Siegelova J, Fiser B, Dusek J. Half-weekly and weekly blood pressure patterns in late human ontogeny. Scripta medica (Brno) 1997; 70: 207-216. 14. Siegelova J, Homolka P, Dusek J, Fiser B, Cornelissen G, Halberg F. Extracircadian-to-circadian variance transpositions early and vice versa late in life in the human circulation. Proceedings, 1st International Symposium, Workshop on Chronoastrobiology & Chronotherapy (Satellite 23 NONINVASIVE METHODS IN CARDIOLOGY 2016 Symposium, 7th Annual Meeting, Japanese Society for Chronobiology), Kudan, Chiyodaku, Tokyo, 11 Nov 2000, pp. 58-60. 15. Singh RB, Cornelissen G, Siegelova J, Homolka P, Halberg F. About half-weekly (circasemiseptan) pattern of blood pressure and heart rate in men and women of India. Scripta medica (Brno) 2002; 75: 125-128. 16. Cornelissen G, Sothern RB, Halberg F. Age and circaseptan-to-circadian prominence of blood pressure in a normotensive clinically healthy man. Abstract 11 in: Eriguchi M (Ed.) Proceedings, 3rd International Symposium: Workshop on Chronoastrobiology and Chronotherapy. Tokyo: University of Tokyo Research Center for Advanced Science and Technology, Nov. 9, 2002. 17. Gubin D, Cornelissen G, Halberg F, Gubin G, Uezono K, Kawasaki T. The human blood pressure chronome: a biological gauge of aging. In vivo 1997; 11: 485-494. 18. Anderson S, Cornelissen G, Halberg F, Scarpelli PT, Cagnoni S, Germanö G, Livi R, Scarpelli L, Cagnoni M, Holte JE. Age effects upon the harmonic structure of human blood pressure in clinical health. Proc. 2nd Ann. IEEE Symp on Computer-Based Medical Systems, Minneapolis, June 26-27, 1989. Washington DC: Computer Society Press; 1989. pp. 238-243. 19. Ikonomov O, Stoynev G, Cornelissen G, Stoynev A, Hillman D, Madjirova N, Kane RL, Halberg F. The blood pressure and heart rate chronome of centenarians. Chronobiologia 1991; 18: 167-179. 20. Watanabe Y, Halberg F, Otsuka K, Cornelissen G. Toward a personalized chronotherapy of high blood pressure and a circadian overswing. Clin Exp Hypertens 2013; 35 (4): 257-266. 21. Cornelissen G, Otsuka K, Uezono K, Siegelova J. Salt, blood pressure, and cardiovascular disease risk. In: Kenner T, Cornelissen G, Siegelova J, Dobsak P (Eds.) Noninvasive Methods of Cardiology. Masaryk University, Brno, Czech Republic 2014; 125-132. 22. Kawasaki T, Itoh H, Cugini P. Influence of reapportionment of daily salt intake on circadian blood pressure pattern in normotensive subjects. J Nutr Sei Vitaminol 1994; 40: 459-466. 23. Halberg F, Cornelissen G, Halberg E, Halberg J, Delmore P, Shinoda M, Bakken E. Chronobiology of human blood pressure. Medtronic Continuing Medical Education Seminars, 4th ed. Minneapolis: Medtronic Inc.; 1988. 242 pp. 24. Halberg F, Nelson W. Chronobiologic optimization of aging. In: Samis H, Capobianco S (Eds.) Advances in Experimental Medicine and Biology, Vol. 108. New York: Plenum Press; 1978. pp. 5-56. 25. Halberg J, Halberg E, Regal P, Halberg F. Changes with age characterize circadian rhythms in telemetered core temperature of stroke-prone rats. J Gerontol 1981; 36: 28-30. 26. Halberg F, Powell D, Otsuka K, Watanabe Y, Beaty LA, Rosch P, Czaplicki J, Hillman D, Schwartzkopff O, Cornelissen G. Diagnosing vascular variability anomalies, not only MESOR-hypertension. Am J Physiol Heart Circ Physiol 2013; 305: H279-H294. 27. Halberg F, Cornelissen G, Otsuka K, Siegelova J, Fiser B, Dusek J, Homolka P, Sanchez de la Pena S, Singh RB, BIOCOS project. Extended consensus on means and need to detect vascular variability disorders (VVDs) and vascular variability syndromes (VVSs). World Heart J 2010; 2 (4): 279-305. 28. Siegelova J, Havelkova A, Dusek J, Pohanka M, Dunklerova L, Dobsak P, Singh RB, Cornelissen G. Seven-day ambulatory blood pressure monitoring: blood pressure variability at rest and during 24 NONINVASIVE METHODS IN CARDIOLOGY 2016 exercise. In: Kenner T, Cornelissen G, Siegelova J, Dobsak P (Eds.) Noninvasive Methods in Cardiology, May 3-4 and October 21, 2013, Brno, Czech Republic. Brno: Faculty of Medicine, Masaryk University. 2013; 87-95. 29. Okajima K, Otsuka K, Oinuma S, Sasaki J, Yamanaka T, Cornelissen G. Aging and within- and between-day variability assessed using 7-day/24-hour ambulatory blood pressure monitoring. J Am Geriatrics Soc 2014; 42 (12): 2440-2442. 30.Shinagawa M, Otsuka K, Murakami S, Kubo Y, Cornelissen G, Matsubayashi K, Yano S, Mitsutake G, Yasaka K-i, Halberg F. Seven-day (24-h) ambulatory blood pressure monitoring, self-reported depression and quality of life scores. Blood Pressure Monitoring 2002; 7: 69-76. 31. Reinberg A, Ghata J, Halberg F, Gervais P, Abulker C, Dupont J, Gaudeau C. Rythmes circadiens du pouls, de la pression arterielle, des excretions urinaires en 17-hydroxycorticosteroides, catecholamines et potassium chez l'homme adulte sain, actif et au repos. Ann Endocrinol (Paris) 1970; 31: 277-287. 32. Stadick A, Bryans R, Halberg E, Halberg F. Circadian cardiovascular rhythms during recumbency. In: Tarquini B (Ed.) Social Diseases and Chronobiology: Proc. Ill Int. Symp. Social Diseases and Chronobiology, Florence, Nov. 29, 1986. Bologna: Societä Editrice Esculapio; 1987. pp. 191-200. Table 1. Circadian rhythm characteristics in subjects of different age groups Age Group k PR (%) P-value M ± SE A (95%CI) (j) (95%CI) Systolic Blood Pressure (mmHg) A,B: <35y 44 21 <0.001 123.4 ± 1.3 9.5 (8.2, 10.7) -232° (-224, -238) C: 35-44y 33 23 <0.001 125.0 ± 1.5 10.4 (8.3, 12.5) -225° (-217, -233) D: 45-54y 80 25 <0.001 125.9 ± 1.0 11.2 (9.6, 12.7) -219° (-215, -224) E: 55-64y 78 15 <0.001 126.1 ± 1.2 8.3 (6.8, 9.9) -214° (-207, -222) F,G: >65y 39 11 <0.001 129.5 ±1.5 6.4 (2.0, 9.2) -215° (-202, -229) Diastolic Blood Pressure (mmHg) A,B: <35y 44 21 <0.001 73.8 ± 1.0 7.4 (6.3, 8.5) -229° (-222, -235) C: 35-44y 33 22 <0.001 79.7 ± 1.3 8.0 (6.4, 9.6) -223° (-215, -233) D: 45-54y 80 25 <0.001 81.2 ±0.8 8.2 (7.2, 9.2) -213° (-208, -218) E: 55-64y 78 15 <0.001 78.6 ±0.8 5.6 (4.7, 6.5) -208° (-202, -216) F,G: >65y 39 12 <0.001 77.2 ± 1.5 4.9 (3.3, 6.5) -211° (-198, -223) Heart Rate (beats/min) A,B: <35y 44 18 <0.001 69.2 ± 1.2 8.4 (7.2, 9.6) -215° (-207, -223) C: 35-44y 33 16 <0.001 71.7 ± 1.4 6.7 (5.3, 8.1) -224° (-214, -236) D: 45-54y 80 19 <0.001 72.6 ±0.9 7.0 (5.8, 8.1) -214° (-207, -221) E: 55-64y 78 13 <0.001 68.1 ±0.9 5.1 (3.9, 6.2) -219° (-210, -228) F,G: >65y 39 14 <0.001 64.8 ± 1.6 5.1 (3.4, 6.8) -217° (-209, -226) 25 NONINVASIVE METHODS IN CARDIOLOGY 2016 PR: Percentage Rhythm, proportion of overall variance accounted for by the fit of a 24-hour cosine curve to individual records; M: MESOR (Midline Estimating Statistic Of Rhythm), a rhythm-adjusted mean; SE: Standard Error; A: 24-hour amplitude; ()>: 24-hour acrophase; CI: Confidence Interval. Acrophase expressed in (negative) degrees, with 360° equated to 24 hours and 0° set to local midnight. Change in the MESOR (M) of Systolic Blood Pressure (SBP) with Age 200 o f R2=0.0604, P=0.032 a m R2=o.0286, P=0.013 180 A A 100 80 15 25 35 45 55 65 75 85 Age (years) Figure 1: The MESOR of systolic blood pressure steadily increases with age, shown by quadratic regression. e Halberg Chronobiology Center. Change in the MESOR (M) of Diastolic Blood Pressure (DBP) with Age 110 o f R2=0.0114, NS a m R2=o.1780, P«0.001 100 O A 0 DBP-M (mmHg) 90 80 70 60 50 /in, A A *A A * A 4 o o g -fft^ aa* 0q * AO* Aq 0 A A* AA tu 15 25 35 45 55 65 75 85 Age (years) Figure 2: The MESOR of diastolic blood pressure reaches a maximum around 53.4 years of age in women and around 50.6 years in men, as shown by quadratic regression. e Halberg Chronobiology Center. 26 NONINVASIVE METHODS IN CARDIOLOGY 2016 Change in the Circadian Amplitude (A) of Systolic Blood Pressure (SBP) with Age 35 o f R2=0.1609, P=0.002 A M R2=0.1760, P=0.001 30 —. 25 1 20 < CL m 15 15 A « A AA „ a ?a A O A OA 4*0 A»*1^* * A ° A 25 35 45 55 Age (years) 65 75 85 Figure 3: The circadian amplitude of systolic blood pressure reaches a maximum around 42.0 years of age in women and around 41.7 years in men, as shown by quadratic regression. e Halberg Chronobiology Center. x E E CO Q Change in the Circadian Amplitude (A) of Diastolic Blood Pressure (DBP) with Age 20 18 16 14 12 10 8 6 4 2 0 15 o f R2=0.0610, P=0.001 a m R2=o.0964, P«0.001 a A a A A a* 2A|a" o4 A : At. st ° a o 4A8$SoA A ; aT A0 o o * o^EWe^ a a 21 A A a *A V- A AAAA ^f^§*V/j S^>/ J5 AOAi ^a1a*a^a AA A O A CA 25 35 45 55 Age (years) Figure 4: 77ze circadian amplitude of diastolic blood pressure reaches a maximum around 35.6 years of age in women and around 39.9 years in men, as shown by quadratic regression. @ Halberg Chronobiology Center. 27 NONINVASIVE METHODS IN CARDIOLOGY 2016 Change in the MESOR (M) of Heart Rate (HR) with Age no 100 o f R2=0.0704, P=0.021 a M R2=0.1145, P«0.001 _ 90 80 oa a?a oi023L?^ "t»*. to I 70 60 50 r6* ▲ A Ag AO a a 0*a 1 02 44A o ▲ a~-. a a 40 15 25 35 45 55 Age (years) Aa a a a a a 65 Aa 75 85 Figure 5: The MESOR of heart rate steadily decreases with age in women and reaches a maximum around 42.8 years of age in men, as shown by quadratic regression. @ Halberg Chronobiology Center. 20 18 16 14 12 10 8 6 4 2 0 Change in the Circadian Amplitude (A) of Heart Rate (HR) with Age o f R2=0.0441, NS a m R2=o.1051, PO.001 A A A O .0 °2 o o ^a a" a fi a* a . AA AA « A AA \ O «A /« OA AA ° O AA A A A 0 15 25 35 45 55 Age (years) 65 75 85 Figure 6: The circadian amplitude of heart rate steadily decreases with age, as shown by quadratic regression. @ Halberg Chronobiology Center. 28 NONINVASIVE METHODS IN CARDIOLOGY 2016 12 10 1 6 E < a. CO . to 4 Infradian to Circadian Spectra of Systolic Blood Pressure in Different Age Groups O A(<25y) -S-B(25-34y) C(35-44y) -O-D (45-54y) -O-E (55-64y) -(> ■ F (65-74y) -9-G (>75y) 3 4 Frequency (cycles/week) Figure 7: Phase-unweighted population-mean least squares spectra of systolic blood pressure in the infradian-to-circadian frequency domain. A decrease in circadian amplitude as a function of age is accompanied by increased amplitudes of components with periods longer than one day. e Halberg Chronobiology Center. 12 10 =5. 6 E < a. 4 Infradian to Circadian Spectra of Systolic Blood Pressure in Different Age Groups O A(<25y) -0-B(25-34y) C (35-44y) •O-D (45-54y) 0--E(55-64y) F(65-74y) G(>75y) 3 4 Frequency (cycles/day) Figure 8: Phase-unweighted population-mean least squares spectra of systolic blood pressure in the circadian-to-ultradian frequency domain. A decrease in circadian amplitude as a function of age is accompanied by increased amplitudes of components with periods shorter than one day. e Halberg Chronobiology Center. 29 NONINVASIVE METHODS IN CARDIOLOGY 2016 Change in the Period (t) of Systolic Blood Pressure (SBP) with Age 30 o F Age (years) Change in the Period (i) of Diastolic Blood Pressure (DBP) with Age 15 25 35 45 55 65 75 85 Age (years) Change in the Period (t) of Heart Rate (HR) with Age 15 25 35 45 55 65 75 85 Age (years) Change in the 95% CI of the Circadian Period (i) of Systolic Blood Pressure (SBP) with Age ft aO a« Jd * Change in the 95% CI of the Circadian Period (t) of Diastolic Blood Pressure (DBP) with Age Change in the 95% CI of the Circadian Period (t) of Heart Rate (HR) with Age Figure 9: W7?/z increasing age, the circadian period is more likely to deviate from 24 hours (left) and the width of its 95% confidence interval increases (right). The latter is statistically significant, except for women's heart rate. e Halberg Chronobiology Center. 30 NONINVASIVE METHODS IN CARDIOLOGY 2016 Relative Change in the 95% CI of the Circadian Amplitude (A) of Systolic Blood Pressure (SBP) with Age *AOA a ° u t . Aa * a '1 o a* a o Relative Change in the 95% CI of the Circadian Amplitude (A) of Diastolic Blood Pressure (DBP) with Age Relative Change in the 95% CI of the Circadian Amplitude (A) of Heart Rate (HR) with Age o '"j^. a^ °o 8 ^oaO-aJ-*----^---" ral_£>a*_o--3."?^T*-ST^ « a a Age (years) Change in the 95% CI of the Circadian Phase () of Systolic Blood Pressure (SBP) with Age o DL 5? o * a aA *^^a^^J*a*^""*^" 4 * Change in the 95% CI of the Circadian Phase () of Diastolic Blood Pressure (DBP) with Age -e-a. ' t^A A V^%|^^-' Change in the 95% CI of the Circadian Phase () of Heart Rate (HR) with Age o o B, Age (years) Figure 10: The width of the 95% confidence interval of the circadian amplitude (normalized by the amplitude) (left) and acrophase (right) increases with age. Results are statistically significant, except for women's heart rate. e Halberg Chronobiology Center. 31 NONINVASIVE METHODS IN CARDIOLOGY 2016 Correspondence: Germaine Cornelissen Halberg Chronobiology Center University of Minnesota, Mayo Mail Code 8609 420 Delaware St. S.E. Minneapolis, MN 55455, USA TEL +1 612 624 6976 FAX +1 612 624 9989 E-MAIL corneOOl @ umn.edu Website: http://halbergchronobiologycenter.umn.edu/ Support: Halberg Chronobiology Fund University of Minnesota Supercomputing Institute A&D (Tokyo, Japan) 32 NONINVASIVE METHODS IN CARDIOLOGY 2016 Lessons Learned from Worldwide Chronobiologically-Interpreted Blood Pressure Monitoring Germaine Cornelissen1, Kuniaki Otsuka2, Jarmila Siegelova3, Jiri Dusek3, Alena Havelkova3, RK Singh4, RB Singh5, Alain Delcourt1, Lyazzat Gumarova6, Yoshihiko Watanabe2, Larry Beaty1 ' Halberg Chronobiology Center, University of Minnesota, Minneapolis, MN, USA 2 Women's Medical University, Tokyo, Japan 3 Masaryk University, Brno, Czech Republic 4 King George's Medical University, Lucknow, India 5 Halberg Hospital and Research Institute, Moradabad, India 6 Al-Farabi Kazakh National University, Almaty, Kazakhstan Dedicated to the memory of Franz Halberg who led the way on this journey. Introduction Only recently do guidelines [1] start considering the circadian variation in blood pressure (BP). For a long time, fixed limits of 140/90 mmHg (systolic/diastolic BP) were used to diagnose hypertension in all adults 18 years and older. The circadian rhythm in BP was thought to primarily reflect the rest-activity schedule rather than being in part endogenous [2]. While this is no longer the case, ambulatory BP monitoring is still restricted to "special cases", often limited to 24 hours. Evidence is presented herein for the need to routinely screen for BP and heart rate (HR) variability, and for continued monitoring in patients in need of treatment. Self-measurements Before the availability of devices for the automatic measurement of BP, chronobiologists relied on self-measurements taken a few times a day for two or more days to assess the circadian variation. Sampling requirements were specified [3] that include the need for at least one nightly measurement, preferably taken by another person in order not to disturb the subject's sleep, Figure 1. Despite the obvious shortcomings of self-measurements, usually taken with a mercury sphygmomanometer, important findings were made that laid the foundation for recognizing the importance of BP variability. Children with a positive family history of high BP and/or related cardiovascular diseases were found to have a larger circadian amplitude of BP than children with a negative such family history in several studies in schools in Italy, Portugal, and several states in the USA (Arkansas, Connecticut, and Minnesota) [4-13]. This result was later extended to neonates [14] once devices for the automatic around-the-clock monitoring of BP became available, in studies conducted in Minnesota, Italy, Japan, Russia, the Czech Republic, and Spain. 33 NONINVASIVE METHODS IN CARDIOLOGY 2016 The Arteriosonde: an analog blood pressure monitor In adults, the first automatic around-the-clock measurements of BP were obtained with the Arteriosonde, within the scope of the Minnesota-Kyushu study of breast cancer risk [15]. This analog device necessitated the manual taking off of data from graphic recordings. Despite this limitation, cardiovascular disease risk was related to the circannual amplitude of both BP and circulating aldosterone, Figure 2 [15, 16]. Portable Nippon-Colin BP monitor With a portable - albeit not ambulatory - monitor from Masayuki Shinoda (Nippon Colin, Komaki, Japan), our first truly automatic BP measurements were collected. It was instrumental in demonstrating that BP increases toward mid-sleep, well before awakening, the latter associated with a larger and faster increase in BP [17], thus providing indirect evidence for the partly built-in nature of the circadian BP rhythm. Indirect evidence for the endogenous nature of the circadian variation in BP had been obtained much earlier by free-running: the circadian period of systolic BP of an afebrile boy with intermittent fever deviated statistically significantly from 24 hours, whereas it remained 24-hour synchronized for core temperature measured concomitantly around the clock [18]. The portable Nippon-Colin BP monitor also served to demonstrate the novelty effect and to assess the extent of day-to-day variability in circadian rhythm characteristics [19-21]. We showed that by extending the monitoring span from 24 to 48 hours, the uncertainty on the estimation of circadian parameters was reduced by 30%, with another 10% gain by prolonging the record to 7 days [7, 19]. Ambulatory BP monitoring The next model from Nippon Colin was the ABPM-630, which operated on gas cartridges. It allowed us to collect around-the-clock data in several populations of clinically healthy individuals on 3 continents from neonates to centenarians, and during pregnancy [22-26]. These data were essential to derive time-specified reference values qualified by gender and age, on which our sphygmochron analysis is based [27-29]. They were critical for the assessment of outcomes from prospective as well as retrospective clinical trials [30]. The latter corroborated the risk associated with an excessive circadian amplitude of BP (CHAT, brief for Circadian Hyper-Amplitude-Tension). Outcome studies in Japan, Taiwan, Minnesota, the Czech Republic, and Germany further identified other abnormalities in the variability of BP and heart rate, which we named Vascular Variability Disorders (VVDs). Ongoing monitoring around the world by BIOCOS investigators and others, first with the ABPM-630, then with the TM-2421 and TM-2430 from A&D (Tokyo, Japan), continues to accumulate evidence for the need to routinely screen for VVDs and for the continued monitoring of patients in need of anti-hypertensive treatment [31]. Treatment is best optimized by timing (chronotherapy) on an individualized basis [32]. VVDs were found to occur in each cooperating center, Figure 3 [33]. Some VVDs were shown to be treatable. Indirect evidence documents that the elimination or reduction of CHAT reduces by more than a factor 2 the incidence of adverse cardiovascular events [34]. 34 NONINVASIVE METHODS IN CARDIOLOGY 2016 Discussion and Conclusion As illustrated above, important lessons were learned from BP monitoring, which now await introduction into routine clinical care with focus on both primary and secondary prevention. Many more applications can benefit from a chronobiologic approach to BP monitoring, such as the determination of healthy lifestyle choices, in terms of tobacco use [35], alcohol consumption [36], salt intake [37], and prayer [38]. Longitudinal monitoring of BP also contributes invaluable information for health surveillance, for monitoring of the environment (e.g., pollution), and even for gaining a better understanding environmental and cosmic influences on physio-pathology [39, 40]. References 1. James PA Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Lackland DT, LeFevre ML, MacKenzie TD, Ogedegbe O Smith SC Jr, Svetkey LP Taler SJ, Townsend RR, Wright JT Jr, Narva AS, Ortiz E. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311(5): 507-520. 2. Halberg F, Cornelissen G, Halberg E, Halberg J, Delmore P, Shinoda M, Bakken E. Chronobiology of human blood pressure. Medtronic Continuing Medical Education Seminars, 4th ed. Minneapolis: Medtronic Inc.; 1988. 242 pp. 3. LaSalle D, Sothern RB, Halberg F. Sampling requirements for description of circadian blood pressure (BP) amplitude (A). Chronobiologia 1983; 10: 138. 4. Halberg F, Haus E, Ahlgren A, Halberg E, Strobel H, Angellar A, Kühl JFW Lucas R, Gedgaudas E, Leong J. Blood pressure self-measurement for computer-monitored health assessment and the teaching of chronobiology in high schools. In: Scheving LE, Halberg F, Pauly JE eds. Chronobiology: Proceedings of the International Society for the Study of Biological Rhythms, Little Rock, Arkansas, November 8-10, 1971. Stuttgart: Georg Thieme Publishers/Tokyo: Igaku Shoin Ltd.; 1974. pp. 372-378. 5. Rabatin JS, Sothern RB, Halberg F, Brunning RD, Goetz FC. Circadian rhythms in blood and self-measured variables of ten children, 9 to 14 years of age. In: Halberg F, Scheving LE, Powell EW, Hayes DK, eds. Chronobiology, Proc. XIII Int. Conf. Int. Soc. Chronobiol., Pavia, Italy, September 4-7, 1977. Milan: II Ponte; 1981. pp. 373-385. 6. Scheving LE, Shankaraiah K, Halberg F, Halberg E, Pauly JE. Self-measurements taught and practiced in public high schools in Little Rock, Arkansas, reveal rhythms and bioergodicity. Chronobiologia 1982; 9: 346. 7. Halberg F, Scheving LE, Lucas E, Cornelissen G, Sothern RB, Halberg E, Halberg J, Halberg Francine, Carter J, Straub KD, Redmond DP. Chronobiology of human blood pressure in the light of static (room-restricted) automatic monitoring. Chronobiologia 1984; 11: 217-247. 8. Goodwin T, Thibodo M, Halberg F, Grimes N, Randall R. Combined self- and automatic monitoring of blood pressure in 15- to 18-year-old Minnesotan students. Chronobiologia 1985; 12: 73-74. 35 NONINVASIVE METHODS IN CARDIOLOGY 2016 9. Scarpelli PT, Romano S, Cagnoni M, Livi R, Scarpelli L, Bigioli F, Corti C, Croppi E, De Scalzi M, Halberg J, Halberg E, Halberg F. The Florence Children's Blood Pressure Study. A chronobiologic approach by multiple self-measurements. Clin Exper Hypertension Part A: Theory and Practice 1985; 7: 355-359. 10. Johns KL, Halberg F, Cornelissen G, März W. Chronobiology at the American International School in Lisbon, Portugal. In: Halberg F, Reale L, Tarquini B, eds. Proc. 2nd Int. Conf. Medico-Social Aspects of Chronobiology, Florence, Oct. 2, 1984. Rome: Istituto Italiano di Medicina Sociale; 1986. pp. 367-384. 11. Scarpelli PT, März W, Cornelissen G, Romano S, Livi R, Scarpelli L, Halberg E, Halberg F. Blood pressure self-measurement in schools for rhythmometric assessment of hyperbaric impact to gauge pressure „excess". In: Dal Palü C, Pessina AC, eds. ISAM 1985, Proc. Int. Symp. Ambulatory Monitoring, Padua, March 29-30, 1985. Padua: CLEUP Editore; 1986. pp. 229-237. 12. Scarpelli PT, Romano S, Cagnoni M, Livi R, Scarpelli L, Croppi E, Bigioli F, März W, Halberg F. Blood pressure self-measurement as part of instruction in the Regione Toscana. In: Halberg F, Reale L, Tarquini B, eds. Proc. 2nd Int. Conf. Medico-Social Aspects of Chronobiology, Florence, Oct. 2, 1984. Rome: Istituto Italiano di Medicina Sociale; 1986. pp. 345-366. 13. Scarpelli PT, Romano S, Livi R, Scarpelli L, Cornelissen G, Cagnoni M, Halberg F. Instrumentation for human blood pressure rhythm assessment by self-measurement. In: Scheving LE, Halberg F, Ehret CF, eds. Chronobiotechnology and Chronobiological Engineering. Dordrecht, The Netherlands: Martinus Nijhoff; 1987. pp. 304-309. 14. Halberg F, Cornelissen G, Bingham C, Tarquini B, Mainardi G, Cagnoni M, Panero C, Scarpelli P, Romano S, März W, Hellbrügge T, Shinoda M, Kawabata Y. Neonatal monitoring to assess risk for hypertension. Postgrad Med 1986; 79: 44-46. 15. Halberg F, Cornelissen G, Sothern RB, Wallach LA, Halberg E, Ahlgren A, Kuzel M, Radke A, Barbosa J, Goetz F, Buckley J, Mandel J, Schuman L, Haus E, Lakatua D, Sackett L, Berg H, Wendt HW, Kawasaki T, Ueno M, Uezono K, Matsuoka M, Omae T, Tarquini B, Cagnoni M, Garcia Sainz M, Perez Vega E, Wilson D, Griffiths K, Donati L, Tatti P, Vasta M, Locatelli I, Camagna A, Lauro R, Tritsch G, Wetterberg L. International geographic studies of oncological interest on chronobiological variables. In: Kaiser H, ed. Neoplasms—Comparative Pathology of Growth in Animals, Plants and Man. Baltimore: Williams and Wilkins; 1981. pp. 553-596. 16. Mandel J, Halberg F, Radke A, Seal U, Schuman L. Circannual variation in serum TSH and prolactin of prostatic cancer patients. Chronobiologia 1980; 7: 129. 17. Halberg E, Halberg F, Shankaraiah K. Plexo-serial linear-nonlinear rhythmometry of blood pressure, pulse and motor activity by a couple in their sixties. Chronobiologia 1981; 8: 351-366. 18. Halberg F, Good RA, Levine H. Some aspects of the cardiovascular and renal circadian systems. Circulation 1966; 34, 715-717. 19. Bingham C, Cornelissen G, Halberg E, Halberg F. Testing period for single cosinor: extent of human 24-h cardiovascular "synchronization" on ordinary routine. Chronobiologia 1984; 11: 263-274. 20. Halberg F, Drayer JIM, Cornelissen G, Weber MA. Cardiovascular reference database for recognizing circadian mesor- and amplitude-hypertension in apparently healthy men. Chronobiologia 1984; 11: 275-298. 36 NONINVASIVE METHODS IN CARDIOLOGY 2016 21. Cornells sen G. Instrumentation and data analysis methods needed for blood pressure monitoring in chronobiology. In: Scheving LE, Halberg F, Ehret CF, editors. Chronobiotechnology and Chronobiological Engineering. Dordrecht, The Netherlands: Martinus Nijhoff; 1987. pp. 241-261. 22. Cornells sen G, Kopher R, Brat P, Rigatuso J, Work B, Eggen D, Einzig S, Vernier R, Halberg F. Chronobiologic ambulatory cardiovascular monitoring during pregnancy in Group Health of Minnesota. Proc. 2nd Ann. IEEE Symp. on Computer-Based Medical Systems, Minneapolis, June 26-27, 1989. Washington DC: Computer Society Press; 1989. pp. 226-237. 23. Cornelissen G, Sitka U, Tarquini B, Mainardi G, Panero C, Cugini P, Weinert D, Romoli F, Cassanas G, Maggioni C, Vernier R, Work B, Einzig S, Rigatuso J, Schuh J, Kato J, Tamura K, Halberg F. Chronobiologic approach to blood pressure during pregnancy and early extrauterine life. Progress in Clinical and Biological Research 1990; 341A: 585-594. 24. Halberg F, Cornelissen G, Bakken E. Caregiving merged with chronobiologic outcome assessment, research and education in health maintenance organizations (HMOs). Progress in Clinical and Biological Research 1990; 341B: 491-549. 25. Hillman DC, Cornelissen G, Scarpelli PT, Otsuka K, Tamura K, Delmore P, Bakken E, Shinoda M, Halberg F, International Womb-to-Tomb Chronome Initiative Group. Chronome maps of blood pressure and heart rate. University of Minnesota/Medtronic Chronobiology Seminar Series, #2, December 1991, 3 pp. of text, 38 figures. 26.Ikonomov O, Stoynev G, Cornelissen G, Stoynev A, Hillman D, Madjirova N, Kane RL, Halberg F. The blood pressure and heart rate chronome of centenarians. Chronobiologia 1991; 18: 167-179. 27. Nelson W, Cornelissen G, Hinkley D, Bingham C, Halberg F. Construction of rhythm-specified reference intervals and regions, with emphasis on „hybrid" data, illustrated for plasma Cortisol. Chronobiologia 1983; 10: 179-193. 28. Halberg F, Delmore P, Halberg F, Cornelissen G, Halberg E, Halberg J, Bakken E, Shinoda M, Cagnoni M, Tarquini B, Scarpelli P, Mainardi G, Panero C, Scarpelli L, Livi R, Cariddi A, Sorice V, Romano S. A blood pressure and related cardiovascular summary: the sphygmochron. In: Tarquini B, Vergassola R, eds. Ill Int. Symposium, Social Diseases and Chronobiology, Florence, Nov. 29, 1986. pp. 3-6. 29. Cornelissen G, Halberg F, Bakken EE, Singh RB, Otsuka K, Tomlinson B, Delcourt A, Toussaint G, Bathina S, Schwartzkopff O, Wang ZR, Tarquini R, Perfetto F, Pantaleoni GC, Jozsa R, Delmore PA, Nolley E. 100 or 30 years after Janeway or Bartter, Healthwatch helps avoid „flying blind". Biomed & Pharmacother 2004; 58 (Suppl 1): S69-S86. 30. Halberg F, Powell D, Otsuka K, Watanabe Y, Beaty LA, Rosch P, Czaplicki J, Hillman D, Schwartzkopff O, Cornelissen G. Diagnosing vascular variability anomalies, not only MESOR-hypertension. Am J Physiol Heart Circ Physiol 2013; 305: H279-H294. 31. Cornelissen G. Prediction and prevention. International Innovation 2015; Issue 181: 77-79. http:// www.internationalinnovation.com/prediction-and-prevention/ 32. Watanabe Y, Halberg F, Otsuka K, Cornelissen G. Toward a personalized chronotherapy of high blood pressure and a circadian overswing. Clin Exp Hypertens 2013; 35 (4): 257-266. 33. Cornelissen G, Delcourt A, Toussaint G, Otsuka K, Watanabe Y, Siegelova J, Fiser B, Dusek J, Homolka P, Singh RB, Kumar A, Singh RK, Sanchez S, Gonzalez C, Holley D, Sundaram B, Zhao Z, Tomlinson B, Fok B, Zeman M, Dulkova K, Halberg F. Opportunity of detecting pre- 37 NONINVASIVE METHODS IN CARDIOLOGY 2016 hypertension: worldwide data on blood pressure overswinging. Biomed & Pharmacother 2005; 59 (Suppl 1): S152-S157. 34. Shinagawa M, Kubo Y, Otsuka K, Ohkawa S, Cornelissen G, Halberg F. Impact of circadian amplitude and chronotherapy: relevance to prevention and treatment of stroke. Biomed & Pharmacother 2001; 55 (Suppl 1): 125s-132s. 35. Scarpelli PT, Livi R, Scarpelli L, Croppi E, Germand G, Cagnoni S, Halberg F. Cigarette-smoking effects on circadian rhythm parameters of blood pressure. Proc. 2nd Ann. IEEE Symp. on Computer-Based Medical Systems, Minneapolis, June 26-27, 1989. Washington DC: Computer Society Press; 1989. pp. 267-272. 36. Cornelissen G, Otsuka K, Watanabe Y, Siegelova J. Alcohol consumption and vascular variability disorders. In: Kenner T, Cornelissen G, Siegelova J, Dobsak P, eds. Noninvasive Methods of Cardiology, October 27, 2014, Brno, Czech Republic. Brno: Masaryk University; 2014. pp. 9-18. 37. Cornelissen G, Otsuka K, Uezono K, Siegelova J. Salt, blood pressure, and cardiovascular disease risk. In: Kenner T, Cornelissen G, Siegelova J, Dobsak P, eds. Noninvasive Methods of Cardiology, October 27, 2014, Brno, Czech Republic. Brno: Masaryk University; 2014. pp. 125-132. 38. Singh RB, Cornelissen G, Kumar A, Bathina S, Halberg F. Larger circadian amplitude of heart rate associated with active prayer in Hindu Indians in Asia. World Heart J 2008; 1 (3): 219-221. 39. Cornelissen G, Halberg F, Breus T, Syutkina EV, Baevsky R, Weydahl A, Watanabe Y, Otsuka K, Siegelova J, Fiser B, Bakken EE. Non-photic solar associations of heart rate variability and myocardial infarction. J Atmos Solar-Terr Phys 2002; 64: 707-720. 40. Halberg F, Cornelissen G, Regal P, Otsuka K, Wang ZR, Katinas GS, Siegelova J, Homolka P, Prikryl P, Chibisov SM, Holley DC, Wendt HW, Bingham C, Palm SL, Sonkowsky RP, Sothern RB, Pales E, Mikulecky M, Tarquini R, Perfetto F, Salti R, Maggioni C, Jozsa R, Konradov AA, Kharlitskaya EV, Revilla M, Wan CM, Herold M, Syutkina EV, Masalov AV, Faraone P, Singh RB, Singh RK, Kumar A, Singh R, Sundaram S, Sarabandi T, Pantaleoni GC, Watanabe Y, Kumagai Y, Gubin D, Uezono K, Olah A, Borer K, Kanabrocki EA, Bathina S, Haus E, Hillman D, Schwartzkopff O, Bakken EE, Zeman M. Chronoastrobiology: proposal, nine conferences, heliogeomagnetics, transyears, near-weeks, near-decades, phylogenetic and ontogenetic memories. Biomed & Pharmacother 2004; 58 (Suppl 1): S150-S187. 38 NONINVASIVE METHODS IN CARDIOLOGY 2016 SINGLE NIGHTLY MEASUREMENT ADDED TO 9 DAYS OF 4-HOURLY SAMPLING DURING WAKING GREATLY IMPROVES ORCADIAN PARAMETER ESTIMATION OF BLOOD PRESSURE (BP)* N of Measurements: 28 29 155 n 140- 125- _ 110 o> X E E. Q. m 95 80 65 50 Systolic 155 M: 132.8........(6.9) A: 6.8...........(-10.3) 0: 14:25........(0:10). P: 0.120 Rhythm Lost T M: A: 0: P: -i- 71.7.........(5.7)........ 5.1...........(-8.4)....... 15:48.......(1:35).......... 0.150 Rhythm Lost =f=F 129.1.......(3.2) \ 13.3........(-3.8) \ 14:05.......(-0:10) \ 0.005.......Rhythm Preserved ...69.2........(3.2) \ 9.1...........(-4.4) 14:51 (0:38) 0.016.......Rhythm Preserved =r=F 02:00 06:00 10:00 14:00 18:00 22:00 02:00 02:00 06:00 10:00 14:00 18:00 22:00 02:00 Time (Clock Hours) 64-year-old man (FH), 2 years after coronary bypass surgery automatically monitored his BP; data folded over Idealized 24-hour day, decimated and rounded to nearest 5 mmHg (as practiced by some but not recommended). M = MESOR; A = circadlan amplitude; 0 ■ circadlan acrophase (referred to 00:00). ' Deviation from all data-based estimates (93 hourly averages). Figure 1: Illustration of the need for nightly measurements of blood pressure to obtain a more reliable estimation of its circadlan variation. ® Halberg Chronobiology Center. Circadian Mesor of Diastolic Blood Pressure (left) and Risk of Diseases Associated with High Blood Pressure (right) Inversely Related to Circannual Amplitude of Plasma Aldosterone* ■ »«v ■ CS» Orcadian Mesor of Diastolic Pressure (Torr) Blood Pressure Risk (arbitrary units) Figure 2: Cardiovascular disease risk and diastolic BP are both related to the circannual amplitude of aldosterone [15]. 0 Halberg Chronobiology Center. 39 NONINVASIVE METHODS IN CARDIOLOGY 2016 Worldwide Blood Pressure Overswinging (CHAT*), A Silent Risk (Greater than that of Hypertension) of Stroke and Other Morbid Events Geographic Locations and Populations Studied * CHAT (Orcadian Hyper-Amplitude-Tension) incidence in several geographic locations. Figure 3: Vascular Variability Disorders (VVDs) such as CHAT (Orcadian Hyper-Amplitude-Tension) are detected in different geographic locations. e Halberg Chronobiology Center. Correspondence: Germaine Cornelissen Halberg Chronobiology Center University of Minnesota, Mayo Mail Code 8609 420 Delaware St. S.E. Minneapolis, MN 55455, USA TEL +1 612 624 6976 FAX +1 612 624 9989 E-MAIL corneOOl @umn.edu Website: http://halbergchronobiologycenter.umn.edu/ Support: Halberg Chronobiology Fund University of Minnesota Supercomputing Institute A&D (Tokyo, Japan) 40 NONINVASIVE METHODS IN CARDIOLOGY 2016 Three Hypertensive Patients' Ambulatory Blood Pressure Reduced by Acupressure Yoshihiko Watanabe1, Franz Halbergt2, Hiroshi Sakura1, Germaine Cornelissen2 ' Tokyo Women's Medical University, Tokyo, Japan 2 Halberg Chronobiology Center, University of Minnesota, Minneapolis, MN, USA f Deceased Aim This study aimed at determining the effectiveness of acupressure at the HE GU (LI-4), GOKOKU point in lowering blood pressure in a small sample of three patients. Any effect on blood pressure variability was also examined. Introduction Ancient traditional Chinese medicine texts include a wide range of indications for Chinese HE GU (LI-4) (in Japanese, GOKORU) point — from headaches and constipation to general pain (1). Today, it is clinically used for "stress", facial pain, headaches, toothaches and neck pain (2, 3). This point has been extensively studied through randomized, controlled trials and clinical research. Recent studies from the Journal of Orofacial Pain showed that the stimulation of HE GU (LI-4) (GOKORU) point significantly reduced myofascial pain of the jaw muscles (2). A recent systematic Cochrane review on acupuncture in migraine and tension-type headaches suggests stimulation of acupoints is an effective and valuable option for alleviating migraines and tension-type headaches (3). HE GU translates in English as "union valley". HE GU (LI-4) (GOKORU) is located at the highest point of the muscle when thumb and index fingers are held close together, a dime-sized spot on the top of the hand, located between the thumb and the forefinger. An effect of acupressure at HE GU (LI-4) (GOKORU) on blood pressure (BP), however, is not well-known. The possibility of lowering BP by non-pharmacologic means was demonstrated earlier by us, using interventions such as autogenic training (4-7). Subjects and methods Three female hypertensive patients, aged 38-68 years (mean ± SD: 53.7 ± 15.0), participated in the study between March and September 2016. All 3 patients were seen at the outpatient clinic of Tokyo Women's Medical University, Medical Center East, or at the Nippori Clinic, in Japan. Despite treatment by non-pharmacologic interventions, such as sodium restriction, for one month or longer, they had not reached the goal for systolic (S)/diastolic (D) BP values below 140/90 mmHg, as recommended by the Japanese Society of Hypertension (JSH) (8). Patients were taught how to self-administer acupressure at the HE GU (LI-4) (GOKORU) point, Figures 1-4. They performed acupressure for 5 minutes on each hand two or three times a day. Instructions were provided as follows: "The HE GU (LI-4) (meaning "union valley" in English) point 41 NONINVASIVE METHODS IN CARDIOLOGY 2016 is a dime-sized spot on the top of the hand, located between the thumb and the forefinger. This point is located at the highest point of the muscle when thumb and index finger are held together. Locate the point between the web of the first and second finger. When applying acupressure, try to relax and breathe deeply as you massage this area. To use acupressure at this point, locate the point, then use deep, firm pressure to massage and stimulate the area for 4-5 seconds. The massage and the acupressure can be done by yourself, or by someone else who is there to assist you." Before starting acupressure and at monthly intervals thereafter, each patient automatically measured SBP, DBP, and heart rate (HR) around-the-clock at 30-minute intervals for 7 days, using the TM-2430 ambulatory monitor from A&D (Tokyo, Japan). Each ABPM record was analyzed by sphygmochron (9, 10). This method involves the least squares fit of a two-component model consisting of cosine curves with periods of 24 and 12 hours to the data, complemented by a non-parametric comparison of the subject's profile to time-specified 90% prediction limits derived from data obtained by clinically healthy peers matched by gender and age. Estimates of the MESOR (Midline Estimating Statistic Of Rhythm, a rhythm-adjusted mean) and of the 24-hour amplitude (half the extent of predictable change within a day based on the 24-hour cosine fit) on treatment were compared to those before start of treatment by Student t-test. Estimates of the standard deviation (SD) of HR and of pulse pressure (PP = SBP-M - DBP-M) were similarly compared. Results Table 1 lists estimates of the MESOR and 24-hour amplitude of SBP, DBP and HR of each subject after 1, 2, and 3 months of treatment, compared to before treatment. Results for PP and HR-SD are also displayed. Since not all subjects provided a 7-day ABPM record at each monthly follow-up, responses from all 3 subjects at all 3 follow-up times were pooled. As seen from Table 1, SBP-M was invariably decreased on treatment as compared to before treatment. On the average, SBP-M was reduced by 5.0 ±2.1 (SE) mmHg in association with acupressure (Student t = 2.308, P=0.041; one-tailed test). On the average, the circadian amplitude of SBP was also reduced by 6.8 ± 3.1 mmHg on treatment (Student t = 2.183, P=0.047; one-tailed test). The MESOR and circadian amplitude of DBP were also reduced, albeit to a lesser extent: DBP-M was lowered by 2.1 ± 1.4 mmHg and DBP-2A by 1.9 ± 1.1 mmHg. A statistically significant decrease of 3.6 ± 1.2 mmHg in PP was demonstrated (Student t = 2.998, P=0.020; two-tailed test). Discussion and conclusion Results on these very few subjects suggest that acupressure at the HE GU (LI-4) (GOKORU) point may also be effective in relation to blood pressure in addition to its effects on pain and headaches. Not only was the MESOR of blood pressure reduced, but the procedure was also associated with a reduction in pulse pressure and in the circadian amplitude of blood pressure. If confirmed on a larger sample size, this finding may be important since an excessive pulse pressure and an excessive circadian amplitude of blood pressure are vascular variability disorders documented to increase cardiovascular disease risk beyond that associated with an elevated BP MESOR (11, 12). Both conditions were diagnosed in one of the three subjects before treatment and were no longer present during treatment. Too large a pulse pressure was also diagnosed in another subject for whom treatment reduced it, but not sufficiently to bring it within acceptable limits. 42 NONINVASIVE METHODS IN CARDIOLOGY 2016 After the several acupressure sessions, participants feel the warmth in their upper body. This feeling may be caused by dilation of the peripheral blood. The reduction of SBP can be accounted for by the vasodilation effect of acupressure. This non-pharmacologic approach to reducing the average blood pressure as well as other abnormalities in blood pressure variability is relatively easy to implement. It can be done without help by another person and it is not overly time-consuming. Further studies should examine whether these results can be extended to larger sample sizes and whether the effect can be sustained on a longer than 3-month basis. References 1. file:///E:/Nobilis/ger/YW/C-Files/Augl6/FPT/Acupressure%20Point%20LI4_%20Large%20 Intestine%206%20or%20He%20Gu%20%E2%80%A2%20Explore%20Integrative%20Medicine. html 2. Shen YF, Younger J, Goddard G, Mackey S. Randomized clinical trial of acupuncture for myofascial pain of the jaw muscles. J Orofac Pain 2009; 23 (4): 353-359. 3.Schiapparelli P, Allais G, Rolando S, Airola G, Borgogno P, Terzi MG, Benedetto C. Acupuncture in primary headache treatment. Neurol Sei 2011; 32 (Suppl 1): S15-S18. 4. Watanabe Y, Cornelissen G, Halberg F, Saito Yoshiaki, Fukuda K, Revilla M, Rodriguez C, Hawkins D, Otsuka K, Kikuchi T. Method and need for continued assessment of autogenic training effect upon blood pressure: case report. New Trends in Experimental and Clinical Psychiatry 1996; 12: 45-50. 5. Watanabe Y, Cornelissen G, Halberg F, Saito Yoshiaki, Fukuda K, Otsuka K, Kikuchi T. Chronobiometric assessment of autogenic training effects upon blood pressure and heart rate. Perceptual and Motor Skills 1996; 83: 1395-1410. ö.Watanabe Y, Otsuka K, Cornelissen G, Halberg F. Emphasis on the need for timing of autogenic training. Perceptual and Motor Skills 1997; 85: 121-122. 7. Watanabe Y, Cornelissen G, Watanabe M, Watanabe F, Otsuka K, Ohkawa S-i, Kikuchi T, Halberg F. Effects of autogenic training and antihypertensive agents on circadian and circaseptan variation of blood pressure. Clin Exp Hypertens 2003; 25: 405-412. 8. The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2014). Hypertens Res 2014; 37: 253-392. 9. Cornelissen G, Halberg F, Bakken EE, Singh RB, Otsuka K, Tomlinson B, Delcourt A, Toussaint G, Bathina S, Schwartzkopff O, Wang ZR, Tarquini R, Perfetto F, Pantaleoni GC, Jozsa R, Delmore PA, Nolley E. 100 or 30 years after Janeway or Bartter, Healthwatch helps avoid „flying blind". Biomedicine & Pharmacotherapy 2004; 58 (Suppl 1): S69-S86. 10. Cornelissen G. Cosinor-based rhythmometry. Theoretical Biology and Medical Modelling 2014; 11: 16. 24 pp. 11. Halberg F, Cornelissen G, Otsuka K, Siegelova J, Fiser B, Dusek J, Homolka P, Sanchez de la Pena S, Singh RB, BIOCOS project. Extended consensus on means and need to detect vascular 43 NONINVASIVE METHODS IN CARDIOLOGY 2016 variability disorders (VVDs) and vascular variability syndromes (VVSs). Leibniz-Online N 5, 2009 (www2.hu-berlin.de/leibniz-sozietaet/journal/archiv_5_09.html). 35 pp. 12.Halberg F, Powell D, Otsuka K, Watanabe Y, Beaty LA, Rosch P, Czaplicki J, Hillman D, Schwartzkopff O, Cornelissen G. Diagnosing vascular variability anomalies, not only MESOR-hypertension. Am J Physiol Heart Circ Physiol 2013; 305: H279-H294. Table 1. Individual responses to acupressure Subject ID SBP-M DBP-M HR-M SBP-2A DBP-2A HR-2A HR-SD PP Before treatment 01NM 153.70 88.50 78.70 38.47 17.07 20.15 11.87 65.20 02AM 139.80 70.90 63.10 25.70 12.01 9.63 6.40 68.90 03FN 139.80 88.30 63.00 7.72 8.61 19.57 10.94 51.50 After 1 month of treatment 01NM 140.60 81.50 74.00 24.19 13.94 19.66 13.44 59.10 02AM 139.00 71.30 63.60 23.04 10.18 12.96 8.03 67.70 03FN After 2 months of treatment 01NM 02AM 135.30 69.50 64.20 16.24 8.39 12.64 7.24 65.80 03FN 135.50 85.40 62.50 10.86 11.01 18.46 12.03 50.10 After 3 months of treatment 01NM 02AM 137.70 71.20 61.00 14.81 8.62 10.53 5.69 66.50 03FN SBP: Systolic Blood Pressure; DBP: Diastolic Blood Pressure; HR: Heart Rate; PP: Pulse Pressure M: MESOR (rhythm-adjusted mean); 2A: double 24-hour amplitude (extend of predictable change within a day); SD: standard deviation. SBP, DBP, PP expressed in mmHg; HR expressed in beats/min. 44 NONINVASIVE METHODS IN CARDIOLOGY 2016 The HE GU (LI-4), GOKOKU point ® © Yoshihiko Watanabe Figure 1: Locating the HE GU (LI-4), GOKORU point. The HE GU (LI-4), GOKOKU point ® © Yoshihiko Watanabe Figure 2: Locating the area of the HE GU (LI-4), GOKORU point to be massaged and stimulated. First, find the highest point of the muscle when the thumb and index finger are held together. 45 NONINVASIVE METHODS IN CARDIOLOGY 2016 The HE GU (LI-4), GOKOKU point ® © Yoshihiko Watanabe Figure 3: Locating the area of the HE GU (LI-4), GOKORU point to be massaged and stimulated: dime-sized spot at the highest point of the muscle when thumb and index finger are held together. The HE GU (LI-4), GOKOKU point @ To use acupressure at this point, locate the point, then use deep, firm pressure to massage and stimulate the area for 4-5 minutes. Figure 4: How to massage and stimulate the HE GU (LI-4), GOROKU point for 4-5 minutes on each hand. 46 NONINVASIVE METHODS IN CARDIOLOGY 2016 Address for correspondence: Yoshihiko Watanabe Department of Internal Medicine, Medical Center East, Tokyo Women's Medical University, 2-1-10 Nishiogu, Arakawa-ku, Tokyo 116-8567, Japan Support: Halberg Chronobiology Fund (GC) 47 NONINVASIVE METHODS IN CARDIOLOGY 2016 48 NONINVASIVE METHODS IN CARDIOLOGY 2016 Changes with Age in the Circadian Rhythm of Circulating Melatonin Cathy Lee Gierke1, Roberto Tarquini2, Federico Perfetto3, Jarmila Siegelova4, Germaine Cornelissen1* 'Halberg Chronobiology Center, University of Minnesota, Minneapolis, MN, USA 2Scuola di Scienze delta Salute Umana, Florence, Italy ^University of Florence, Florence, Italy 4Masaryk University, Brno, Czech Republic * To whom correspondence should be addressed Abstract A number of variables are known to decrease in circadian amplitude as we age, and advance in circadian phase: prolactin, estrogens (El and E2), 17-OH-progesterone, aldosterone, DHEA-S. The same has been found in blood pressure and heart rate. Various coronary artery disease (CAD) factors are known to be lowered by melatonin treatment. Here we look at the effect of age and gender on the circadian rhythm (MESOR, amplitude and acrophase) of melatonin. Circulating melatonin was measured every 4 hours for 24 hours in 345 mostly healthy subjects from Florence, Italy. A circadian rhythm was clearly identified using 24-hour cosinor of log10-transformed data. Linear and quadratic regressions clearly show a decreasing circadian amplitude of melatonin with age. A plateau or uptick in melatonin amplitude is seen for the oldest age group, in quadratic regressions, possibly reflecting a healthier melatonin amplitude and better overall health in those who live longer. Parameter tests on the results from population-mean cosinor analyses show the MESOR is higher in women than men, and the amplitude is larger in men than in women. And the acrophase shifts earlier by about one hour in men. Introduction Melatonin is a primary factor in the modulation of circadian rhythms, acting as a synchronizer of hormones and systems throughout the body, including the sleep/wake cycle. Circulating melatonin peaks as you become drowsy, and drops when you awaken. Blue light, a component of daylight (sunlight) on earth, is believed to be a synchronizer for melatonin. Melatonin is reduced upon exposure to blue light. Electronics and some types of LED lighting give off blue light, and can interfere with normal circadian rhythms, especially after evening exposure (Stevens et al., 2013). Circadian disruptions are associated with negative health effects, and are thus important to predict and understand. Melatonin has been observed to lower blood pressure, and when given before bed, it amplifies the night-time dip, increasing circadian amplitude (Grossman et al., 2006; Zaslavskaya et al., 2003; Zeman et al., 2005). Such an increase in amplitude is associated with increased health. Caution must be used, however, to be sure the amplitude does not become too large, as a blood pressure amplitude that is too large can also be unhealthy (Halberg et al., 2003). Oxidative stress has been proposed as one of the major mechanisms leading to the development of pulmonary hypertension (Qiao et al., 2015). Melatonin is a very powerful free-radical scavenger and anti-oxidant, which may be how it reduces blood pressure. It also acts to enhance the effect of other 49 NONINVASIVE METHODS IN CARDIOLOGY 2016 anti-oxidants. And unlike other radical scavengers, its metabolites are anti-oxidants (Anisimov et al., 2006). Vitamin E is the next most effective radical scavenger we know of, after melatonin, and it is only half as effective. Melatonin interacts with the immune system, creating an anti-inflammatory effect (Anisimov et al., 2006). In addition to reducing blood pressure, melatonin treatment has been shown to reduce the pulsatility index in the internal carotid artery, decrease platelet aggregation, and reduce serum catecholamine and norepinephrine (but not epinephrine) concentrations (Arangino et al., 1999; Pandi-Perumal et al., 2016). Low circulating melatonin values are reported in individuals with CAD, arterial hypertension, and congestive heart failure (Pandi-Perumal et al., 2016). The morning reduction in melatonin may constitute one of the mechanisms of the morning peak in frequency of cardiovascular events. Impacts and pathways of interaction are numerous. It will be beneficial to gain further insight into melatonin's impact on cardiovascular health. Herein we further analyze melatonin data from a previously published study (Tarquini et al., 1997) to look at changes with age. A number of variables, including melatonin (Cornelissen et al., 2000), are known to decrease in circadian amplitude as we age. Prolactin, estrogens (El and E2), 17-OH-progesterone, aldosterone, DHEA-S all exhibit a circadian amplitude that is statistically significantly reduced in post-menopausal women as compared to adult menstruating women (Halberg et al., 1981). In addition, a number of variables also advance in circadian phase. We demonstrated in several populations that the circadian amplitude of blood pressure and heart rate decreased in older people, and the acrophase advanced (Zaslavskaya et al., 2003). Table 1: Decreased circadian amplitude with age of several hormones Hormone (units) N Group 1 Group II Group III Prolactin (ng/ml) 29 12.4 16.5 11 El (pg/ml) 27 17.6 15.9 11.4 E2 (pg/ml) 26 28 28.4 8.1 17-OH Progesterone (pg/ml) 29 181 196 128 Aldosterone (ng/dl) 25 4.1 2.5 1.8 DHEA-S (ng/ml) 28 580 370 230 Note: Groups I and II: adult menstruating women; Group III: post-menopausal women. (Halberg et al., 1981) Materials and Methods Circulating melatonin was measured by radioimmunoassay from 345 (244 women, 101 men) mostly healthy subjects in two separate studies in Florence, Italy. Ages varied from 20 to 90 years (mean ± SD: 48.5 ± 17.1). Intra- and inter-assay coefficients of variation were 6.6% and 5.9%, respectively; sensitivity was 3 pg/ml. Measurements were taken every 4 hours over 24 hours (at 08:00, 12:00, 16:00, 20:00, 00:00 and 04:00). The data were log10-transformed to normalize their distribution. One-way ANOVA was performed on the transformed data from a subset of 133 women and 61 men (study A), separately by gender, 50 NONINVASIVE METHODS IN CARDIOLOGY 2016 across five age categories (20-25, 26-40, 41-60, 61-75, >75 years) to test the equality of the means at each of the 6 timepoints. Each subject's data had previously been analyzed (Tarquini et al., 1997) by cosinor (Halberg, 1980; Cornelissen, 2014) to obtain estimates of the rhythm-adjusted mean (MESOR, Midline Estimating Statistic Of Rhythm), the amplitude and the acrophase (phase of maximum by reference to local midnight) of a 24-hour cosine. The procedure is illustrated for one subject in Figures 1 & 2, using the freely-available software CATkit (z.umn.edu/CATkit). Regression with age was performed on the MESOR and amplitude for each gender. Both linear and quadratic regressions were done in each case. Each analysis was performed on the two study groups (A & B), separately, and together. A population-mean cosinor was performed, by gender and age group, on individual MESORs, amplitudes and acrophases from the 24-hour cosinor fit, resulting in a population MESOR and a vectorial average of the circadian amplitude-acrophase pair. Tests comparing these resulting parameters (Bingham et al., 1982) were done to test the equality of circadian parameters between age groups and gender. 24 hours Till o io M >o Time (hours) Figure 1: Subject 10. Grey line is the time course of melatonin over 24 hours. The light blue line is the cosinor model used to estimate MESOR, amplitude and acrophse (phi). 51 NONINVASIVE METHODS IN CARDIOLOGY 2016 c 2 1-20 S 1-00 00 o Females 1 - Time (Clock hours) Age Group -•-82-90 ♦"61-75" -±-"41-60" -*-"26-40" "20-25" Figure 3: Mean and SE melatonin at each sampling time, for 5 age groups in women of Study A. Notice the oldest age group has the largest swing, going lower in the day and higher at night. Results Averages for each age group of the log10-transformed data from Study A are plotted in Figures 3 & 4. One-way ANOVA shows that differences in melatonin between the 6 time points are statistically significantly different from zero for both genders and all age groups, supporting the presence of a circadian rhythm (invariably P<0.05). O tuO O iviaies MeaniSE —— 8:00 12:00 16:00 20:00 0:00 4:00 Age Group -♦-"61-78" -■-"41-60" -*-"27-40" -*-"20-26" Time (Clock hours) Figure 4: Melatonin at each sampling time, for 4 age groups in men of Study A. Notice the youngest age group has the largest concentration at night. (One 78 year-old was included in the 61-75 group.) 52 NONINVASIVE METHODS IN CARDIOLOGY 2016 There are less than half as many men as women (244 vs 101) in the study. Also, there are only 5 men over the age of 75, in the combined studies, and only 1 in study A. With these qualifications, regression analyses of the cosinor-obtained MESOR with age (Figure 5) for the combined studies showed no statistically significant change across age groups. Males Females _ 1.6 QJ 2 s M O _l oc O 5 L rear 1: ♦ * ♦ * ♦ ♦ * * 2) 30 40 50 60 70 So 90 2 0 30 40 5,0 70 80 90 100 Age (years) Age (years) Figure 5: MESOR of melatonin regressed over age The regression does show, however, a decrease in circadian amplitude with age in both men and women (Figure 6). But we are also seeing a possible uptick, or at least a leveling off of the decrease in amplitude. In men (Figure 6), there is a large uptick in amplitude in the oldest age group, albeit it may stem in part from the small number of men over 75 years. 20 iO 40 50 60 70 HQ üq 20 jo 40 so 60 70 80 90 100 Age (years) Age (years) Figure 6: 24-hour amplitude of melatonin regressed over age Looking at the two studies separately, the uptick in amplitude was not consistently apparent in every grouping. Figure 7 shows results of regressions for Study B, where a decrease in amplitude with 53 NONINVASIVE METHODS IN CARDIOLOGY 2016 age is again significantly present. The decrease in MESOR is also significant for females in Study B, where it was not in the combined studies, but it is not significant for males. 01 "S ♦J "o. E < Sj UJ 5 Females -ö.ioo 2Q 40 60 80 Age (Years) 100 Females 100 Age (Years) Maies — poiv-M -Ö.2DÜ 2D 30 40 50 60 70 SO « Age (Years} 2.000 1.500 1.000 0.6DD -L# X Males 0.000 •Poty. (r> -Linear (Y) ♦ ♦ ♦ ♦ ♦ J. .!.. 40 SO 60 70 «0 Age (Years) Figure 7: The uptick in amplitude seen in the full population is not consistently present in Study B. The population-mean cosinor assesses the presence of a rhythm on a population basis, provided subjects represent a random sample of the population, as can be assumed in this study. It calculates a population MESOR and a vectorial average of the circadian amplitude-acrophase pair for the population from rhythm characteristics of individual subjects. This method is used to validate a circadian rhythm in the population; in this study, a circadian rhythm is validated for all age groups of both genders, except for the oldest age group in men, which is very small. Full results are shown in Table 2. Results from a comparison of circadian rhythm characteristics between men and women are shown in Table 3. Table 2A: Females: Population-mean cosinor results HHI Mesor [ Amplitude Aoro-phase P-value <26 22 1.058 0.666 -46 <0.001 27-40 77 0.988 0.504 -43 <0,0Q1 41-&0 89 0.933 0.484 -48 <0,QQ1 61-75 40 1.048 0,287 -53 <0.QQ1 >75 14 0.894 0.458 -48 <0.001 Table 3: Parameter tests of Population-Mean Cosinor results Mesor 14.9131 0.0001 Amplitude 10.9342 0.0010 Acrophase 0.6308 0.4276 (A, phi) 5.4838 0.0043 54 NONINVASIVE METHODS IN CARDIOLOGY 2016 Table 2B: Males: Population-mean cosinor results Age Count Amplitude P-value <26 9 0.789 0.824 -52 0.003 27-40 33 0.893 0.78 -54 <0.001 41-60 31 0.822 0.473 -39 <0.001 61-75 23 0.719 0.563 -48 <0.001 >75 5 0.882 0.555 -37 0.106 Plots (Figures 8, 9, and 10) of the MESOR, amplitude and acrophase (obtained by population-mean cosinor) as they change across age groups, for each gender give a visual representation of these changes by age. 1.2 0.6 -1-1-1-1-1-1 <26 27-40 41-60 61-75 >75 Age Groups Figure 8: Population-mean cosinor MESOR estimates in 5 different age groups: Parameter test comparing MESOR for men or women across age groups shows no significant difference across ages, for either gender (Men: F=0.86; P=0.49; Women: F=1.38; P=0.24) Women have a significantly higher MESOR than men (F=14.913; P=0.0001). Figure 9: Population-mean cosinor 24-hour amplitude estimates in 5 different age groups. Parameter test comparing amplitude for men or women across age groups shows there is a significant drop across ages, for both genders (Men F=3.26; P=.015; Women F=4.07; P=.0033). Men have a significantly higher amplitude than women (F=10.934; P=.001). 55 NONINVASIVE METHODS IN CARDIOLOGY 2016 3 -SO -75 -60 -45 -30 -15 <26 27-40 41-60 Age (Yea r s) 61-75 >75 6:00 4:00 0:00 Figure 10: Acrophase plot. Parameter test comparing acrophase for men or women shows there is a significant advance of log(Melatonin) acrophase across ages for men, but no significant change for women (Men: F=2.63, P=0.039; Women: F=0.698, P=0.594). Men (-52° -> -39°) -52 min earlier; Women (-46° -> 48°). There is no significant difference between men and women acrophases. From Figures 8-10 it can be seen that 1. Circadian amplitudes of log(melatonin) fall with age in both women and men; 2. There is a plateau, or slight uptick in amplitude in the oldest women and men; 3. The circadian amplitude of log(melatonin) is higher in men than in women; 4. The MESOR of log(melatonin) is higher in women than in men; 5. The circadian acrophase shifts earlier by approximately 1 hour in men. No shift seen in women. Conclusions Numerous studies have found a decreasing amplitude and a phase advance with increasing age, in diverse variables, just as we have found with melatonin. Low circulating concentrations of melatonin are also reported in individuals with CAD, and congestive heart failure. Less well known is the possible plateauing or even rebound seen in the very old, although it has been observed in several endpoints of heart rate variability, including RR50, SDmean, and HF power (Otsuka, 1998). The uptick or plateau may be a product of the oldest group being the healthier individuals, in view of the old age they have reached. Further study is needed. The uptick in amplitude of melatonin in the oldest age group further motivates the question of whether studies should carefully adjudicate the state of health or disease in elderly subjects and whether to include those who are not clinically healthy. Given that lower amplitudes are associated with both aging and the presence of disease in many variables, is the trend toward lower amplitudes in melatonin with aging, found herein, a reflection of disease status, or is it a reflection of aging? One avenue toward unraveling the confounding of disease status and aging is through the use of longitudinal studies, where those who develop disease can be removed from the population, improving the ability to distinguish between "healthy" aging, and those who develop disease (or show pre-disease states) with aging. The trend toward increasing amplitudes in the oldest age groups supports a need for age- and gender-appropriate reference data, from longitudinal studies, which can provide a more refined understanding of what constitutes "healthy" patterns in circulating melatonin. 56 NONINVASIVE METHODS IN CARDIOLOGY 2016 The Halberg Chronobiology Center has built this type of reference database for blood pressure and heart rate, based on gender- and age-appropriate metrics from healthy individuals, allowing a more accurate gauge of an individual's blood pressure health. We use this age-appropriate indicator to identify potential health risks, where the AMA uses single blood pressure measurements for individuals 18 years and older, of either gender. A reference database of age- and gender-appropriate values for melatonin, or any molecule or variable, would be a step toward a more refined understanding of health, and more proactive diagnostics for practitioners. References 1. Anisimov VN, Popovich IG, Zabezhinski MA, Anisimov SV, Vesnushkin GM, Vinogradova IA. Melatonin as antioxidant, geroprotector and anticarcinogen. Biochimica et Biophysica Acta (BBA) - Bioenergetics. 2006;1757(5-6): 573-589. 2. Arangino S, Cagnacci A, Angiolucci M, Vacca AM, Longu G, Volpe A, et al. Effects of melatonin on vascular reactivity, catecholamine levels, and blood pressure in healthy men. The American Journal of Cardiology. 1999; 83(9): 1417-1419. 3. Bingham C, Arbogast B, Cornelissen Guillaume G, Lee JK, Halberg F. Inferential statistical methods for estimating and comparing cosinor parameters. Chronobiologia 1982; 9: 397-439. 4. Cornelissen G. Cosinor-based rhythmometry. Theoretical Biology and Medical Modelling 2014; 11: 16. 24 pp. 5. Cornelissen G, Halberg F, Burioka N, Perfetto F, Tarquini R, Bakken EE. Do plasma melatonin concentrations decline with age? The American Journal of Medicine. 2000; 109(4): 342-344. ö.Grossman E, Laudon M, Yalcin R, Zengil H, Peleg E, Sharabi Y, et al. Melatonin reduces night blood pressure in patients with nocturnal hypertension. The American Journal of Medicine. 2006; 119(10): 898-902. 7. Halberg F. Chronobiology: methodological problems. Acta Med Rom 1980; 18: 399-440. 8. Halberg F, Cornelissen G, Katinas G, Syutkina EV, Sothern RB, Zaslavskaya R, et al. Transdisciplinary unifying implications of circadian findings in the 1950s. Journal of Circadian Rhythms 2003; 1: 2. 61 pp. www.JCircadianRhythms.com/content/pdf/1740-3391-l-2.pdf 9. Halberg F, Cornelissen G, Sothern RB, Wallach LA, Halberg E, Ahlgren A et al. International geographic studies of oncological interest on chronobiological variables. In: Kaiser H (Ed.) Neoplasms—Comparative Pathology of Growth in Animals, Plants and Man. Baltimore: Williams and Wilkins; 1981. pp. 553-596. 10. Otsuka K (Ed.) Chronome & Janus-medicine: Heart Rate Variability (HRV) and BP Variability (BPV) from a viewpoint of chronobiology and ecology. Tokyo: Kyowa; 1998, 224 pp. 11. Pandi-Perumal SR, BaHammam AS, Ojike NI, Akinseye OA, Kendzerska T, Buttoo K, et al. Melatonin and human cardiovascular disease. J Cardiovasc Pharmacol Ther 2016; doi: 10.1177/1074248416660622. 57 NONINVASIVE METHODS IN CARDIOLOGY 2016 12. Qiao Y, Guo W, Li L, Shao S, Qiao X, Shao J, et al. Melatonin attenuates hypertension-induced renal injury partially through inhibiting oxidative stress in rats. Molecular Medicine Reports 2016; 13(1): 21-26. 13. Stevens RG, Brainard GC, Blask DE, Lockley SW, Motta ME. Adverse health effects of nighttime lighting. American Journal of Preventive Medicine. 2013; 45(3): 343-346. 14. Tarquini B, Cornelissen G, Perfetto F, Tarquini R, Halberg F. Chronome assessment of circulating melatonin in humans. In vivo 1997; 11: 473-484. 15. Zaslavskaya RM, Makarova LA, Shakarova AN, Komarov F, Wang ZR, Wan C, et al. Individualized time series-based assessment of melatonin effects on blood pressure: Model for pediatricians. Neuroendocrinology Letters. 2003; 24(Suppl. 1): 238-246. lö.Zeman M, Dulkovä K, Bada V, Herichovä I. Plasma melatonin concentrations in hypertensive patients with the dipping and non-dipping blood pressure profile. Life Sciences 2005; 76(16): 1795-1803. 58 NONINVASIVE METHODS IN CARDIOLOGY 2016 Seven Day /24 h Ambulatory Blood Pressure Monitoring: Circadian Variability of Pulse Pressure Jarmila Siegelova12, Jiří Dušek2, Alena Havelková12, Michal Pohanka1, Leona Dunklerová12, Petr Dobšák12, Germaine Cornelissen3 'Department of Physiotherapy and Rehabilitation, 2Department of Sports Medicine and Rehabilitation Masaryk University, Brno CZ, St. Anna University Hospital Brno, 3Halberg Chronobiology Center, Minnesota University, USA Introduction Excessive pulse pressure is defined by a difference between systolic and diastolic blood pressure record more than 60 mmHg. Acceptable pulse pressure is below 60 mmHg. According vascular variability disorders excessive pulse pressure increase risk of increased cardiovascular morbidity and mortality (1-4). Excessive pulse pressure is evaluated from casual measurement of blood pressure. Casual blood pressure has great variability during 24-h and there are not enough information about the variability of the pulse pressure during seven day/ 24 hour blood pressure monitoring in man. From seven day /24 hour blood pressure monitoring it is possible by means of diagnosis of vascular variability disorders (WD) evaluate also pulse pressure and other factors. Beside of increased mean 24-hours values of BP evaluated using Halberg cosinor analysis (we call it MESOR for rigorous mathematical approach and increased MESOR is an attribute of MESOR hypertension), there are excessive differences between day and night BP values (CHAT), the excessive pulse pressure and the decreased heart rate variability. Our results using the determination of pulse pressure by means of seven day/24h ambulatory BP monitoring showed increased variability of pulse pressure in every subject day by day and the seven day mean value of pulse pressure could show us the real risk of this parameter (5-16). On October 6, 2008, consensus meeting held at Masaryk University, Brno, Czech Republic, St.Anna Teaching Hospital, proposed current guidelines for diagnosing high blood pressure, so-called MESOR hypertension, connected with other "Vascular Variability Disorders", Excessive pulse pressure, Circadian-Hyperaplitude-Tension, Deficient Heart Rate Variability, diagnosed on seven day/24 hour ambulatory blood pressure measurement. The leading scientist was Prof.Dr.Franz Halberg, d.h.mult. with other participants Prof. Dr. Germaine Cornelissen, Dr. Othild Schwarzkopff, University of Minnesota, USA, Halberg Chronobiology Center, Prof.Dr.Thomas Kenner, D.H.c.mult., University Graz, Austria, Prof. MUDr. Jarmila Siegelová, DrSc, Prof. MUDr.Bohumil Fišer,CSc, Prof. MUDr. Petr Dobšák,CSc, MUDr.Jifí Dušek, CSc, Prof. MUDr. Zdenék Placheta, DrSc, MUDr. Pavel Homolka, PhD., Dr. Mohamned Al-Kubati, PhD. Masaryk University Brno, St.Anna Teaching Hospital, CZ participated on this consensus and signed the consensus (Fig. 1). Other important data and results were brought by the members of the international BIOCOS project ( Japan, Russia, India, USA, Mexico, Europa). Excessive pulse pressure is important risk factor for cardiovascular morbidity and mortality, but there is not enough information about the variability during seven day/ 24 hour blood pressure monitoring in man. From seven day /24 hour blood pressure monitoring it is possible by means of diagnosis of vascular variability disorders (WD) evaluate also pulse pressure and other factors (1-4). 59 NONINVASIVE METHODS IN CARDIOLOGY 2016 Evaluation of hypertension is determined by two factors. If we start from the calculation of lost years of healthy life, hypertension is the most important disease globally. Treatment of hypertension can avoid negative impact of the disease on mortality and morbidity. Side effects of drug therapy of hypertension are relatively mild, so it pays to treat everybody and to avert such adverse event - stroke, myocardial infarction or cardiac death. We prefer therapy of high blood pressure which is still based on more than century - old method of measuring blood pressure in the doctor's office. The shortcomings of this approach are already known. Australian study from 1980 showed that 40% of patients were wrongly diagnosed as in hypertensive placebo - treated branches were normotensive at the next examination, and originally normotensive were at follow-up examination hypertensives (17). The fact is explained by the high variability of blood pressure measurement in the doctor's office and the statistical phenomenon of regression to the mean, no effect of treatment with placebo. Modern approach was proposed already 60 years ago by founder of chronobiology Prof. Franz Halberg Minnesota from Minnesota, USA and it is ambulatory blood pressure measurements. We published the first Czech study using ambulatory blood pressure monitoring 23 years ago together with Prof. Bohumil Fiser, dr. Jiří Dušek, Prof. Bořivoj Semrád, Prof. Germaine Cornelissen and Prof. Franz Halberg (18). Notwithstanding modern guidelines for the diagnosis and treatment of hypertension (6) do not give priority of ambulatory monitoring in the diagnosis of hypertension as a method of the first choice, although the financial costs ambulatory blood pressure monitoring significantly decreased in the last time. The ambulatory blood pressure monitoring can be replace by home blood pressure measurements carried out by the patient using low-cost automatic device several times day. The fact that the therapy proceed according to the principle, initiate treatment in case of doubt, it is advantageous for both pharmaceutical companies and patients carefully taking care of your health. On the other hand, the fact that we treat more patients unnecessarily, it leads medical team to inconsistencies in the medical therapy control and there is not inconsistent pressure on the patient to comply with treatment regimens, including prescribed drug. It is therefore desirable for both the doctor and the patient in the group of hypertensive patients greatly diversify approach and focus on patients with a higher risk of organ damage, adverse events and premature death. This allows us to diagnosis of vascular variability disorders on the basis of long-term ambulatory blood pressure monitoring or home measurement of blood pressure patients (1-4). Vascular Variability Abnormalities (VVAs) or Disorders (VVDs) include with an elevated blood pressure (BP) (MESOR-hypertension), an excessive pulse pressure (EPP), too large a circadian amplitude of BP (CHAT, short for Circadian-Hyper-Amplitude-Tension), an odd timing of the circadian variation in BP but not of heart rate (HR) (ecphasia), too small a standard deviation of HR (DHRV, short for deficient HR Variability), to high pulse pressure and a circadian period of BP and HR deviating with statistical significance from 24 hours when measured under ordinary conditions in a 24-hour synchronized environment (ecfrequentia). Vascular variability disorders are based on mathematical methods for the assessment of dynamics of long lasting, also seven days /24 hour ambulatory blood pressure monitoring originally prepared by Prof. Dr. Germaine Cornelissen, revised in Brno, by those undersigned (Fig. 1) (1). The aim of the present study was to assess excessive pulse pressure from long lasting blood pressure monitoring. Our study is aimed to determinate of pulse pressure by means of seven day/24h ambulatory BP monitoring showed increased variability of pulse pressure in every subject day by day and the seven day mean value of pulse pressure could show us the real risk of this parameter. 60 NONINVASIVE METHODS IN CARDIOLOGY 2016 Excessive pulse pressure (PP) can be calculated as the difference between SBP and DBP mean value of hourly measured blood pressure around the 24 hours; is in terms of increased brachial pulse pressure more than 60 mmHg. Increased brachial pulse pressure is associated with another increased risk of cardiovascular morbidity and mortality. It is another factor of vascular variability disorder. In this study we evaluated circadian variability of pulse pressure from seven day /24 hours ambulatory blood pressure monitoring. EXTENDED CONSENSUS ON NEED AND MEANS TO DETECT VASCULAR VARIABILITY DISORDERS (VVDs) AND VASCULAR VARIABILITY SYNDROMES (VVSs)* Franz Halberg1, Germaine Cornélissen1, Kuniaki Otsuka2, Jarmila Siegelova3, Bohumil Fišer3, Jiří Dušek3, Pavel Homolka3, Salvador Sánchez de la Peňa\ R.B, Singh5 and the BIOCOS project 1 Halberg Chronobiofogy Center, University of Minnesota, Minneapolis, Minnesota, USA.: Tokyo Women's Medical University, Daini Hospital, Tokyo, Japan.5 Masaryk University, Brno, Czech Republic.' Chronomics Research Center, ENMH-IPN, Mexico City, Mexico. s Halberg Hospital and Research Institute, Centre of Nutrition and Heart Research, Moradabad, India Prof MUDr I Ii Hill Thrill Mi DrSc. Ikad Der*. ofPhygothcnqn MC Organization of Syphosiinn om Nooiavavc KonbloJog} ft_ -t't/ ^.-i,c Prof MUDr BohofJ») Fi*«. CSc llmt DtpL ofthyfology MlJ. cmcnlu. Minis* pf Meahh Octrh RcpuMk. cmcnms rm-n'Hrr ofhwfd of die WIK) ^-Z^- Prof. MUDr. DobUk. CSc. Ikad Dcpt of KcKabürtabon MU /<^^'/ Prof. Zdenfk Pbchet». DrSc Emeritus tfead Dept. of Rcfebiliuiiji« MU Ml'Dr Pavel Homoka. Ph_D. >kid. I>pt of J-unctKrcal ßiagKXftc ffe&Ut ^ MUUr.titiUuMlNead.Dept lorPort-nduatcfcducauon AssisL Plut Molbuitd AkKilwli. Pti.I).. 1- iKfi of Hituitiip am! i- IJcr« Of Pro] IKniiii keimet. MI). Ausiria. ementus pntxxfent t ro\rrot> of Graz, Austrta. Pt* OlhiM VhN*;»rt A ufiff M D MiIW-t« f'rir™r*«>|f>j> Cnin I Viivertitx ..l" Vi™«..i=. Prof. fttteHaJbcrg.M.D.Haiberg(.hronobiotoiy Cctitre.Univenityof Muin^u. USA Prof German» Cornělissen. PhD. Dept Integrative Biolog and Physiology, co-Director. Halber* Chroiiobiolozy Center Unrversrry of Minnesota. USA Figure 1: Brno Consensus in: Intl. J. of Geronto-Geriatrics, 11 (14) 119-146, December 2008 61 NONINVASIVE METHODS IN CARDIOLOGY 2016 Methods Subjects From our Brno database of 496 patients with ambulatory monitoring of blood pressure for seven day/24 hours, thirty patients were recruited for seven-day blood pressure monitoring. One-hour means of systolic and diastolic blood pressure were evaluated, when night-time was considered from midnight to 0600 h and day time from 1000 to 2200 h, avoiding the transitional periods. Mean day-time and mean night-time systolic and diastolic pressures were evaluated every day, and from this data we calculated pulse pressure. 7-day monitoring of blood pressure was made by means of the instrument TM - 2421 of Japanese firm AD operating on the principle of oscillometric analysis. The instrument measured blood pressure for 7 days repeatedly every 30 min from 5 to 22 o'clock and once an hour from 22 to 5 o'clock. We calculated the 7-day mean for pulse pressure and every day mean for pulse pressure. The study was approved by local ethics committee and the patients signed the informed consent. Results The patients were ordered according mean 7-day SBP (patient No 1: 107 mmHg, patient No 30: 131 mmHg; median value: 123 mmHg). The variability of one-daytime SBP values during 7-day monitoring is seen in Fig. 2. Taking 135 mmHg of day-time systolic pressure as a threshold for indication to treatment, then 13 patients (43 %) were under this value every day and nobody was over this value every day. 17 patients (57 %) were one day indicated for treatment and the other day not. The night-time SBP values are seen in Fig. 3. Similarly, if 120 mmHg of night-time systolic pressure is the threshold, then 10 subjects (33 %) were indicated one day for treatment and the other day not. Corresponding value of threshold for diastolic day-time pressure is 85 mmHg, thus 22 patients (73 %) were one day indicated for treatment and the other day not (Fig. 4) and for night diastolic pressure of 70 mmHg 24 patients (80 %) were indicated one day for treatment and the other day not. Only one patient (3%) was indicated for treatment every day on the DBP night basis (Fig. 5). Those data demonstrate large day-to-day SBP and DBP mean day-time and mean night-time variability. 62 NONINVASIVE METHODS IN CARDIOLOGY 2016 Seven-day monitoring SBP day 160 140 o> 120 E rf 100 m co c re E d) E 80 60 I 40 20 V Patient No Figure 2: 77ze variability of one-daytime SBP values during 7-day monitoring. The patients were ordered according mean 7-day SBP (patient No 1: 107 mmHg, patient No 30: 131 mmHg; median value: 123 mmHg). One-day mean values (point) and 7-day mean values (dash) are indicated. 63 NONINVASIVE METHODS IN CARDIOLOGY 2016 180- 160 140 E E 120 Q. CQ OT 100 c n q> E 80 Patient No (p" 55 mmHg (n = 29) P Age (years) 80.3 ± 8.4 78,8 ± 7,6 83,5 ± 9,4 0.11 Sex ratio (M/F) 0.48 0.5 0.45 0.86 Mean aortic gradient (mmHg) 45.5 ± 18 48 ± 18 40.1 ± 1.3 0.16 Aortic valve area (cm2) 0.74 ±0.18 0.72 ±0.14 0.75 ± 0.23 0.61 Mean pulmonary artery pressure (mmHg) 29.3 ±9.7 24.2 ± 7.2 41.4 ±6.5 < 0.001 Mean capillary wedge pressure (mmHg) 18.4 ±8.3 14.3 ±5 28.3 ±5.5 < 0.001 Diastolic ulmonary gradient (dPAP -PCWP) -0.07 ± 4 0.48 ±3.9 -1.5 ±4.6 0.17 Table 2: Left ventricular measurements Overall population (n = 80) sPAP < 55 mmHg (n = 51) sPAP > 55 mmHg (n = 29) P LV ejection fraction (%) 61.7 ± 14.3 63.9 ± 12.3 55.6 ± 17.6 0.07 LV mass, indexed (g/m2) 147.6 ±41.2 146.9 ±35.8 155.8 ±49.3 0.5 LV longitudinal strain (%) - 16.4 ±4.3 - 16.8 ±4.2 - 13.6 ±3.4 0.07 LV end diastolic diameter (mm) 51.6 ± 6.7 50.5 ± 5.3 55.4 ± 7.7 0.02 E/A ratio 0.96 ± 0.5 0.76 ± 0.21 1.52 ± 0.64 < 0.001 E/e' ratio 17.7 ± 7.02 15.7 ± 5.9 22.5 ± 7.4 0.001 E deceleration time (ms) 209.3 ± 81.2 230 ± 83.4 169.5 ± 64.8 0.02 106 NONINVASIVE METHODS IN CARDIOLOGY 2016 Table 3: Left atrial measurements Overall population (n = 80) sPAP < 55 mmHg (n = 51) sPAP > 55 mmHg (n = 29) 1 " 1 LA volume (ml/m2) 49.9 ±29 47.4 ±31.5 59.8 ±21.9 0.13 LA strain (4 c view) 17.4 ± 7.6 20.4 ± 6.65 10.7 ± 5.3 < 0.001 LA strain (2 c view) 18.5 ± 8.05 21.1 ± 8.2 9.9 ± 5.5 < 0.001 Table 4: Predictors of severe PH > 55 mmHg (univariate analysis) Factors (95% IC) r P Age 0.32 (-0.19 to 0.85) 0.17 0.21 Aortic valve area -5.1 (-33.9 to 23.6) -0.05 0.72 Mean aortic gradient -0.24 (-0.05 to 0.01) -0.27 0.06 LV end diastolic diameter 1.09 (0.4 to 1.8) -0.27 0.002 LV ejection fraction -0.29 (-0.6 to 0.07) -0.25 0.11 Indexed LV mass 0.08 (-0.003 to 0.17) 0.22 0.06 Indexed LA volume 0.14 (-0.04 to 0.3) 0.26 0.14 LV strain 1,44 (0.16 to 2.7) 0.42 0.028 E deceleration time -0.07 (-0.12 to -0.02) -0.36 0.006 E/A ratio 16 (12.3 to 19.9) 0.50 < 0.001 E/e' ratio 0.77(0.26 to 1.27) 0.33 0.004 TAPSE -1.14 (-2.02 to -0.25) -0.41 0.012 S Tricuspid annulus -0.002 (-0.04 to 0.04) -0.002 0.90 sPAP/TR 0.78 (0.58 to 0.99) 0.76 < 0.001 LA strain 4 c view -1.43 (-1.95 to -0.91) -0.68 < 0.001 LA strain 2 c view -1.13 (-1.59 to -0.67) -0.67 < 0.001 Patients were 80 year-old in average. Regarding left ventricular measurements, ejection fraction, mass and longitudinal strain were not significantly different between the 2 groups but end-diastolic diameter was higher (Tab. 1). 107 NONINVASIVE METHODS IN CARDIOLOGY 2016 Patients with severe pulmonary hypertension had more severe diastolic function parameters than other patients, with higher E/A and E/e' ratios and shorter E wave deceleration times. Regarding left atrial measurements, the left atrial volume was higher in patients with severe pulmonary hypertension, but the difference was not statistically significant. However, the left atrial systolic longitudinal strain, which is a parameter of left atrial reservoir function, was more severely decreased in patients with severe pulmonary hypertension, with a highly significant difference compared to patients with lower pulmonary artery pressures (Tab. 2, 3). In univariate analysis, the predictors of severe pulmonary hypertension were the left ventricular end diastolic diameter, the left ventricular systolic longitudinal strain, the diastolic function parameters, the TAPSE, the tricuspid regurgitant velocity, and the left atrial strain (Tab. 4). However, in multivariate analysis, the only independent echocardiographic parameter associated with severe pulmonary hypertension was the left atrial strain, with a good negative correlation: the more the left atrial strain decreases, the more the systolic pulmonary artery pressure increases (figure 1). -r 10 T 20 strainog4cmoy apsyst Fitted values Figure 1: Relationship between left atrial strain and systolic pulmonary artery pressure ROC analysis showed that with a cut off value of 13%, left atrial strain was predictive of a systolic pulmonary artery pressure above 55 mmHg with a sensitivity of 85% and a specificity of 78% (figure 2). 108 NONINVASIVE METHODS IN CARDIOLOGY 2016 O O - A o O - d 0.00 0.25 0.50 1 - Specificity 0.75 1.00 Area under ROC curve = 0.8408 Figure 2: ROC analysis for left atrial strain predicting systolic pulmonary artery pressure above 55 mmHg Discussion In a normal heart, left heart chambers are compliant and the pressures are low. In heart failure with preserved ejection fraction, pathophysiology of increased pulmonary pressure is usually considered to be due to a stiff left ventricle, but this can only explain increased diastolic pressures. In systole, the mitral valve is closed, so the final chamber is the left atrium which has consequently an important reservoir function; if the left atrium in non-compliant, there is an increased V wave and an increased systolic artery pressure. Therefore, in aortic stenosis, we could propose the following paradigm: aortic stenosis is a model of heart failure with preserved systolic function; as the left ventricle becomes stiffer, the diastolic pressure increases, the left atrial is submitted to an increased afterload and becomes stiffer itself, and as it loses its reservoir function the systolic pulmonary arterial pressure increases. Conclusion Thirty six % of patients with AS had severe PH > 55 mmHg. PH is not predicted by AS severity, LV mass or ejection fraction. Patients with PH have worse LV diastolic function and LV longitudinal 109 NONINVASIVE METHODS IN CARDIOLOGY 2016 strain. In multivariate analysis LA strain measured by speckle tracking analysis is the only independent predictor of pulmonary artery pressure in patients with severe AS These results suggest that the increase in systolic PAP is tightly linked to the decrease in left atrial reservoir function. The prognostic value of LA strain should be further assessed. References 1. Ben-Dor I, Goldstein SA, Pichard AD, et al. Clinical Profile, Prognostic Implication, and Response to Treatment of Pulmonary Hypertension in Patients With Severe Aortic Stenosis. Am J Cardiol 2011;107:1046-1051. 2. Kapoor N, Varadarajan P, G. Pai RG. Echocardiographic predictors of pulmonary hypertension in patients with severe aortic stenosis. Eur J Echocardiogr 2008; 9: 31-33. 3. Malouf JF, Enriquez-Sarano M, Pellikka PA, Oh JK, Bailey KR, Chandrasekaran K et al. Severe pulmonary hypertension in patients with severe aortic valve stenosis: clinical profile and prognostic implications. J Am Coll Cardiol 2002;40:789-95. 4. Silver K, Aurigemma G, Krendel S, Barry N, Ockene I, Alpert J. Pulmonary artery hypertension in severe aortic stenosis: incidence and mechanism. Am Heart J 1993;125:146-50 5. Johnson LW, Hapanowicz MB, Buonanno C, Bowser MA, Marvasti MA, Parker FB, Jr. Pulmonary hypertension in isolated aortic stenosis. Hemodynamic correlations and follow-up. J Thorac Cardiovasc Surg 1988;95:603-7. 6. Aragam JR, Folland ED, Lapsley D, Sharma S, Khuri SF, Sharma GV. Cause and impact of pulmonary hypertension in isolated aortic stenosis on operative mortality for aortic valve replacement in men. Am J Cardiol 1992;69:1365-7. 7. Melby SJ, Moon MR, Lindman BR, Bailey MS, Hill LL, Damiano RJ Jr. Impact of pulmonary hypertension on outcomes following aortic valve replacement for aortic valve stenosis. J Thorac Cardiovasc Surg. 2011; 141:1424-30. 8. Cam A, Goel SS, Agarwal S, Menon V, Svensson LG, Tuzcu EM, Kapadia SR. Prognostic implications of pulmonary hypertension in patients with severe aortic stenosis. J Thorac Cardiovasc Surg 2011;142:800-8. 9. Dalsgaard M, Egstrup K, Wachtell K, Gerdts E, Cramariuc D, Kjaergaard J, Hassager C. Left atrial volume in patients with asymptomatic aortic valve stenosis (the Simvastatin and Ezetimibe in Aortic Stenosis study). Am J Cardiol 2008;101:1030-4. 10. O'Connor K, Magne J, Rosea M, Pie' rard LA, Lancellotti P. Impact of aortic valve stenosis on left atrial phasic function. Am J Cardiol 2010;106:1157-62. 11. Casaclang-Verzosa G, Malouf JF, Scott CG, Juracan EM, Nishimura RA, Pellikka PA. Does left atrial size predict mortality in asymptomatic patients with severe aortic stenosis? Echocardiography 2010;27:105-9. 110 NONINVASIVE METHODS IN CARDIOLOGY 2016 12. Todaro MC, Carerj S, Khandheria B, Cusma-Piccione M, La Carrubba S, Antonini-Canterin F, Pugliatti P, Di Bello V, Oreto G, Di Bella G, Zito C. Usefulness of atrial function for risk stratification in asymptomatic severe aortic stenosis. J Cardiol 2016;67:71-9. 13. Galli E, Fournet M, Chabanne C, Lelong B, Leguerrier A, Flecher E, Mabo P, Donal E. Prognostic value of left atrial reservoir function in patients with severe aortic stenosis: a 2D speckle-tracking echocardiographic study. Eur Heart J Cardiovasc Imaging. 2016;17:533-41. 14. Guazzi M, Galie N. Pulmonary hypertension in left heart disease. Eur Respir Rev 2012;21:338-46. Ill NONINVASIVE METHODS IN CARDIOLOGY 2016 112 NONINVASIVE METHODS IN CARDIOLOGY 2016 Vascular Function in Health and Disease: A Gender Comparative Study Irhad Trozic1, Dieter Platzer2, Nandu Goswami1 ' Gravitational Physiology and Medicine research unit, Institute of Physiology, Medical University of Graz, Austria 2 Institute of Biophysics,, Medical University of Graz, Austria Objectives Orthostasis or drop in blood pressure during upright posture, is a product of the activity of the gravitational force on the cardiovascular system, which if the cardiovascular system is not able to compensate will cause loss of consciousness, or syncope In some people by which, because of different pathological condition, the cardiovascular system is not able to maintain a normal blood pressure during upright posture, and leads to syncope. Postural hypotension in the elderly age group, reduces cerebral blood flow and carries considerable morbidity from dizziness, falls and injury. In acute stroke, cerebral perfusion is dependent on systemic blood pressure because cerebrovascular autoregulation is impaired. Thus, postural hypotension in acute stroke patients may further impair cerebral blood flow, increase stroke risk, or hinder recovery. Methods This study consist of three cohorts: (A), (B), and (C). Subjects: In the cohort (A) we will examine (60) Healthy volunteers (males, n=30; females, n=30) with no histories of vasovagal syncope. Subjects should be non-obese, not on any medications and non-smokers. Any pathological (neurological, cardiovascular, endocrine) condition will be considered an exclusion criterion. Exercise and engaging in stressful activity 2 days before the tests will not be allowed. Furthermore, 24 hours before commencement of the tests abstinence from coffee and other stimulants will also be required. To compensate for random and unavoidable climatic effects on the cardiovascular system, every day one protocol (at 9-1 lam) will be performed. All subjects will be tested during the same time of the day for all the trials. In the cohort (B) we will examine elderly patients with Parkinson' disease, PD (n=20), Alzheimer's disorder, AD (n=20), or Stroke (n=20) will do a sit-to-stand test for 6 min every three months and vascular responses monitored. Each subject will do a sit to stand test between 9-1 1 am, every 3 monthly. While in the seated position, subjects will be fitted with a non-invasive blood pressure monitor and a three-lead ECG (see below) as well as a Transcranial Doppler device. In cohort (C) is a control group, and will be examined age matched healthy subjects (n=60). Experimental equipment: Endothelial dysfunction will be assessed by non-invasive flow-mediated dilatation (MyLab Five Ultrasound Colour Doppler, and Cardiovascular Suite). Hemodynamic monitoring will include blood pressure (upper arm oscillometry and finger plethysmography), heart rate (3-lead ECG) and thoracic impedance measurements using a Task Force Monitor® (TFM, CNSystems, Graz, Austria). Power spectrum analysis of heart rate (HR) variability assesses sympathovagal balance. Low (LF: 0.04 - 0.15 Hz) and high frequency (HF: 0.15 - 0.40 Hz) power components of RR- 113 NONINVASIVE METHODS IN CARDIOLOGY 2016 intervals (RRI)\ diastolic blood pressure (DBP) and systolic blood pressure (SBP) will be evaluated. Baroreceptor sensitivity will be calculated from continuous monitoring of HR and SBP. As vascular changes over time may affect blood flow to the brain, cerebral blood flow velocity will be measured using transcranial Doppler ultrasonography (Doppler-Box, DWL, Sipplingen, Germany). At the end of 30 min supine rest period and post pre-syncope and 15 and 30 min following pre-syncope, 20 ml blood will be collected. We will measure: Plasma volume changes; Plasma hormones: aldosterone, PRA, arginine vasopressin (AVP), adrenomedullin and galanin will be measured. Expected results 1. We expect that the result will show differences in the orthostatic responses between males and females. Some studies suggest that the stroke volume and stroke index paramters were lower in women compared with men and that women have higher HR during progressive LBNP and at pre-syncope compare to men. (Fu Q. at all, 2004). In another study the results indicate that elderly men have poorer orthostatic tolerance under enduring postural stress then women of the same age (Mellingsaeter R. M, 2013). 2. Also we expect that differences in orthostatic responses between old healthy and stroke subjects. The results of a prospective study reveal the abolition of the circadian rhythm of heart rate variability and a loss of the relative vagal nocturnal dominance in patients with acute ischemic stroke (Korpelainen T. J at al, 1997). In another study it was observed that during passive head up tilting, patients with histories of stroke show drops in blood pressure (Enishi et al., 2004). 3. Also Differences in hemodynamic parameters over seasons. Based on the data from our pilot studies- in which we observed seasonal variations in some volume regulating hormones-, we expect that orthostatic tolerance will vary across seasons Expected impact With this project we will achieve significant information on the effects of orthostatic load and circannual rhythms on vascular and endothelial function in patients with PD/ AD/ Stroke. In a future scenario our results can be used for power/sample size calculations. Expected is also a contribution on prevention and treatment of falls to save in lives and cost of the public health system. Syncope is dangerous due to injury sustained when subjects fall, resulting in fractures. Knowledge from this project will lead to lives saved, by reducing number/ severity of syncopal events and falls. Falls are common among elderly, and elderly women fall nearly twice as often as men, albeit differences seem to disappear after the age of 90. Reasons for fall are multiple: gait and balance disturbances, use of sedatives, polypharmacy, reduced muscle strength, frailty, acute and chronic diseases, dementia, poor vision and syncope. However, among elderly people, gender differences in orthostatic tolerance and potential mechanisms are even less studied, possibly because it is difficult to separate changes due to disease and medication from aging of the cardiovascular system. At last we expect the improving of treatments of cardiovascular disorders. With increasing age, the frequency of cardio-vascular events and syncope increases. We wish to establish whether orthostatic load, circadian rhythms and seasonality affect endothelial function in healthy young subjects and the elderly, with/without PD/ AD/ Stroke and across gender. 114 NONINVASIVE METHODS IN CARDIOLOGY 2016 References 1. Fu Q. Vassoconstrictor Reserve and Sympathetic Neural Control of Orthostasis. Ciruculation, 2004;110(18),2931-2937. 2. Mellingsaeter R M, Wyller VB, Wyller TB, Ranhoff AH. Gender Differences in Orthostatic Tolerance in the Elderly. Aging Clinical and Experimental Research, 2013;4,659-665. 3. Enishi K, Tajima F, Akomoto H, Mita R. Initial drop f blood pressure during head-up in patients with cerebrovascular accidents. Environmental Health and Preventive Medicine, 2004;5,255-300. 115 NONINVASIVE METHODS IN CARDIOLOGY 2016 116 NONINVASIVE METHODS IN CARDIOLOGY 2016 Variabilität in der Blutdruckmessung Prof. MTJDr. Jarmila Siegelova, DrSc. Department of Physiotherapy and Rehabilitation, Department of Sports Medicine and Rehabilitation, St. Anne's University Hospital, Masaryk University Brno, Czech Republic 1- J Medizin! iche Universität Graz Zentrum Im Physiologische Medizin Institut nil Physiologie Harrachgasse 2i/v MWlOGraz Tel »43/ »16 I 380-4:60 4:61 Fa« »43 / 316 / 360-9630 Einladung zu einem Gastvortrag von Prof. MUDr. Jarmila Siegelova Dept. of Sports Medicine and Rehabilitation Faculty of Medicine, Masaryk University, Brno Variabilität in der Blutdruckmessung" Freitag, 8. Juli 2016; 10:00 Uhr Seminarraum 07.51, Institut für Physiologie Vorklinik. Harrachgasse 21/V Medenache Unrv*rsitX Graz. Au*nbru99«pljQ 2. »40M dru www medumgruat ü© ATU PI 11171 Ig—M^l oJTi AaaT« ^MWiai 6V» fT13-:30C««*»*:CC4 BC 6KAUA~*'A jmron »r-n Ks t-ulKCXCCCOUK0v Body Surface Are* 632 Kl \ «w cMr.tM.it "»0« 16a0(cm] Hematocrf 400I%] Weight 56 0 [kg) Arm length 50 0 [cm] ICG Electrode distance 3S 0 (cm) Rho 126 3 [Ohm'om] Page 1 of 1 TASK rVfi.CZ MONITOR Date of Measurement 2005-06-15 Measurement Time 09 30 34 STUOY: TTT CONDITION DateofPnnt 2005-06-23 Timeof Pnnt 12 17 16 Program Version 2 1 0 24 One-page diagnostic disclosure Mean=92 4.50*9 1 iMin=62 5 Max=203 Ol 200^ Itl ^^^^^^ ^^^ä~^v * Mear>=122 7.SD-5.1 rlG3 1) Mcao-8l l.SO-3 3 lMm=71 5 Mi.-91 91 Mcan=62 6.SO-V7 iMin=S4 9,Ma*=70.0| Mean=66 6 SD=4 6 (Min*52 7.Max*t02 4| Mean=37 8.SD = 2 6 |Mm=32 1,Max=63.3! Mcan=4 4 SD-0 4 JMin=3.5.Ma*=6.2) I IL Mean'3 5 SO=0 2 tMin=<\6.Ma»=7 0) Mean=l60S.SD=l38 (M.m-t179 Max-2028! HRV-RR r>« IS'JI 40 35 30 25 20 10 5 0 Means2i70.SD»1S3 41 ( 70X> I«hl d«r dttltol. W«rl» > BSaaMgji 49 t 77X) • • iiattml . • ttiiinmi |/iUl HiltoUttto )•» » u»u«l Accutracker II Report 123 NONINVASIVE METHODS IN CARDIOLOGY 2016 Mittelwerte in Stunden von systolischem und diastolischem Blutdruck (±SD) während 24-Stunden ambulanter Blutdruckmessung in einer Gruppe von Patienten mit behandelter nephrogener Hypertonie (gefüllte Symbole) und einer Gruppe von Patienten mit unbehandelter essentieller Hypertonie (offene Symbole). Mittelwerte in Stunden von systolischem und diastolischem Blutdruck (±SD) während 24-Stunden ambulanter Blutdruckmessung in einer Gruppe von Patienten mit behandelter nephrogener Hypertonie (gefüllte Symbole) und einer Gruppe von Patienten mit behandelter essentieller Hypertonie mit Enalapril (offene Symbole). 124 NONINVASIVE METHODS IN CARDIOLOGY 2016 Mittelwerte in Stunden von systolischem und diastolischem Blutdruck (±SD) während 24-Stunden ambulanter Blutdruckmessung in einer Gruppe von Patienten mit behandelter nephrogener Hypertonie (gefüllte Symbole) und einer Gruppe von Normotonikern (offene Symbole). Baroreflexsensitivität (±SD) in Normotonikern (C), bei Patienten mit essentieller Hypertonie behandelt mit Placebo (EH P), bei Patienten mit essentieller Hypertonie behandelt mit Enalapril (EH T), und bei Patienten mit nephrogener Hypertonie behandelt mit Enalapril (NHT). 125 NONINVASIVE METHODS IN CARDIOLOGY 2016 Zusammenarbeit mit der Universität Minnesota Franz Halberg, M.D., Dr. h.c. (Montpellier), Dr. h.c. (Ferrara), Dr. h.c. (Tyumen), Dr. h.c. (Brno), Dr. h.c. (L'Aquila), Dr. h.c. (People's Friendship University of Russia, Moscow), Professor of Laboratory Medicine and Pathology, Physiology, Biology, Bioengineering and Oral medicine, Director, Halberg Chronobiology Center, University of Minnesota, USA (1919-2013) 126 NONINVASIVE METHODS IN CARDIOLOGY 2016 mm C "• l u< -m 1 ' » -«1—1............— . '^^^ : "-,—,- .) • S A S C - controls, EH - essential hypertension, SAS - sleep apnea syndrom Halberg Cosinor Analyse 127 NONINVASIVE METHODS IN CARDIOLOGY 2016 Acrophases N - controls, EH - essential hypertension, SAS - sleep apnea syndrom Acrophases N - controls, EH - essential hypertension, SAS - sleep apnea syndrom 128 NONINVASIVE METHODS IN CARDIOLOGY 2016 Risikofaktoren für Ischämischen Schlaganfall Circadianer HyperAmplituden-Tonus (kurz CHAT) Positive Familien- SBD- Risiko-Faktoren: Gewicht Hohes anamnese Alter MESOR BD-A >25 Choles- für hohen >60 >130 mm >90ten kg/m2 terol Trinken" BD Rauschen Jahren Hg Perzentil Zahl der Patienten Risiko-Faktor vorhanden ? ja 88 148 152 102 207 80 52 176 32/25 nein 209 149 145 195 90 217 245 121 265/272 *Kg/m2 ist positiv mit dem BD-MESOR korreliert "Alkohol-Verbrauch erhöht BD-A "'Relatives Risiko (RR) ist ein Risiko (ausgerechnet als Verhältnis der Inzidenzen) Patienten mit einem Risikofaktor (z.B., Rauchen oder überschwellige BD-A) (im Nenner) zu dem Risiko von Patienten ohne Risikofaktor (im Kenner) (deren RR=1) 129 NONINVASIVE METHODS IN CARDIOLOGY 2016 Sieben Tage/ 24-stunden Ambulante Blutdruckmessung SEVEN-DAY AMBULATORY BLOOD PRESSURE MONITORING 14.4. — 20.4.1996 sieben Tage nicht-invasive Blutdruckmessung an der Person von Professor Fiser In den Jahren 1996 - 2008 wurden 307 Tests von siebentägiger, 24 Stunden ambulanter Blutdruckmessung aufgezeichnet und diese Resultate bilden die „Datenbank Brno". Diese Daten haben wir in Brno als Mittelwerte analysiert und auch an das Halberg-Chronobiology Center (Minnesota) geschickt. Prof. Cornelissen hat diese Daten mittels Halberg'scher Cosinor-Analyse ausgewertet. 130 NONINVASIVE METHODS IN CARDIOLOGY 2016 Erhöhter Blutdruck: Diagnose und Behandlung Für die Diagnose der Hypertonie gilt bis zum heutigen Tag die dreimalige Sprechstundenmessungen des Blutdrucks in Abständen von 7 Tagen, wie es schon seit 1904 und auch in der Zwischenzeit vorgeschlagen wurde. Die ambulante 24-Stunden Blutdruckmessung, zur Zeit die entscheidende Instanz, ist für eine Diagnose wichtig. Am Halberg Chronobiology Center wurden über viele Jahre die Daten von 24-Stunden ambulanten Blutdruckmessungen von mehreren Staaten gesammelt. Die Europäische Gesellschaft für Hypertonie („European Society of Hypertension") analysierte die 24 Stunden ambulante Blutdruckmessung mit Grenzwerten für Hypertonie. 2007 hat die ESH eine Auswertung für Diagnose von Hypertonie publiziert und darin die Grenze für Hypertonie in mmHg festgelegt und zwar für Sprechstundenmessung, ambulante 24- Stundenmessung und Selbstmessung des Blutdruckes zu Hause. Table 5 Blood pressure thresholds (mmHg) for definition of hypertension with different types of measurement SBP DBP Office or clinic 140 90 24-hour 125-130 80 Day 130-135 85 Night 120 70 Home 130-135 85 J Hypertension, 2007 131 NONINVASIVE METHODS IN CARDIOLOGY 2016 Brno Database Unsere Resultate von 7 Tage/24 Stunden ambulanter Blutdruckmessung zeigen eine grosse intraindividuale Variabilität im Blutdruck zwischen verschiedenen Wochentagen. Seven-day monitoring SBP day 160 140 O) 120 E f 100 m V) Š 80 a> E a E "•M I 40 60 20 • . • . » 'iTTittrr,TŤ>T1 ••. . ♦: v ^ & v 40 co Q 20 • T • • I 1 tfH.Ýfíti.t8:t; V q>, ^ <ír NV ^ ^ ^ ^ ^ ^ ^ Patient No 22 Patienten (73 %) waren 1 Tag über dem Wert von 85 mmHg, diese Werte des diastolischen Blutdruckes entsprechen der Diagnose für hohen Blutdruck - Hypertonie und den zweiten Tag unten dem Wert von 85 mmHg. Seven-day monitoring DBP night Ol X E E Q. m Q c CO CD E (D E 100 90 80 70 60 50 40 30 20 10 0 — • • • • • ; j • . t—.4-1. s •—iT«i .—TT-I--*- * 8 N? «ŕs V &