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E pisodic hypertension, maximum systolic blood pressure (SBP), and visit-to-visit variability in SBP between clinic appointments 1,2 were strong predictors of incident and recurrent cardiovascular events in 5 large cohorts. Calcium channel blockers (CCBs) and thiazide diuretics reduced maximum SBP and SBP variability in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA) and Medical Research Council 2 (MRC-2) studies compared with renin-angiotensin system inhibitors (RASi) or β-blockers, 3 explaining differences in stroke risk between treatment groups, with similar effects in meta-analyses of all published studies. [4][5][6] Drug effects on SBP variability were seen in a wide range of patients 4 and persisted when used in combination. 7 However, clinical readings are impractical for prospectively assessing the effects of drug changes on SBP variability and maximum SBP, particularly in secondary prevention of acute cerebrovascular events when rapid control of BP variability may be desirable. 8 Furthermore, clinical readings in these randomized trials were performed during office hours with no consistent time of measurement. Therefore, clinical readings from randomized controlled trials (RCTs) cannot be used to determine differences in drug class effects on BP variability at different times of day.Day-to-day SBP variability on home BP monitoring (HBPM) is also significantly associated with the risk of stroke and cardiovascular events in both primary prevention 9,10 and cerebrovascular disease, 11 with particularly strong associations on day-to-day readings in the early morning, before the time of clinical readings used in estimating visit-to-visit BP variability. 9,10 This may reflect the association between the Background and Purpose-Visit-to-visit variability in systolic blood pressure (SBP) is associated with an increased risk of stroke and was reduced in randomized trials by calcium channel blockers and diuretics but not by renin-angiotensin system inhibitors. However, time of day effects could not be determined. Day-to-day variability on home BP readings predicts stroke risk and potentially offers a practical method of monitoring response to variability-directed treatment. Methods-SBP mean, maximum, and variability (coefficient of variation=SD/mean) were determined in 500 consecutive transient ischemic attack or minor stroke patients on 1-month home BP monitoring (3 BPs, 3× daily). Hypertension was treated to a standard protocol. Differences in SBP variability from 3 to 10 days before to 8 to 15 days after starting or increasing calcium channel blockers/diuretics versus renin-angiotensin system inhibitors versus both were compared by general linear models, adjusted for risk factors and baseline BP. Results-Among 288 eligible interventions, variability in SBP was reduced after increased treatment with calcium channel blockers/diuretics versus both versus renin-angiotensin system inhibitors (−4.0 versus 6.9 versus 7.8%; P=0.015), primarily because of effects on maximum SBP (−4...

Introduction: Infective endocarditis (IE) is a life-threatening condition with significant morbidity and mortality, and can require surgical repair. Case Report: A 36-year-old man presented to the emergency department for worsening dyspnea and chest pain. Point-of-care echocardiography demonstrated a mobile oscillating mass on the aortic valve with poor approximation of the valve leaflets, suggesting aortic valve insufficiency secondary to IE as the cause of acute heart failure. The patient underwent emergent aortic valve replacement within 24 hours. Discussion: While point-of-care echocardiography has been well documented in identifying tricuspid vegetations, aortic valve involvement and subsequent heart failure is less well described. Earlier recognition of aortic valve vegetations and insufficiency can expedite surgical intervention, with decreased complication rates linked to earlier antimicrobial therapy. Conclusion: This case report highlights the ability of point-of-care ultrasound to identify aortic vegetations, allowing for the earlier diagnosis and therapy.