Cancer mortality trends in two cohorts of elderly people having different life-styles

We analyzed cancer mortality trends in 3282 elderly subjects from two general Italian populations with different life-style patterns taking part in the Cardiovascular Study in the Elderly (CASTEL). The aim of the study was to evaluate which predictors were able to influence cancer mortality. Age, gender, tobacco smoking, the presence of respiratory symptoms, increased serum levels of ALT and ALP, and the town of residence were powerful predictors. Subjects living in Chioggia (low income, rural) had significantly greater lung and liver cancer mortality, compared with those living in Castelfranco (industrial). The findings suggest that an incongruous life-style (smoking, alcohol consumption, poor hygienic conditions) may increase cancer mortality despite the favorable environmental conditions typical of rural Mediterranean areas.

24-hour leg and forearm haemodynamics in transected spinal cord subjects

OBJECTIVE

A circadian rhythm of blood pressure has been demonstrated both in subjects who are physically active during the day and in those confined to bed. The study of the circadian rhythm of arterial flow and peripheral resistance, on the other hand, is limited to pioneer experiments. This paper is aimed at demonstrating that leg peripheral resistance has circadian fluctuations which are modulated by spinal neural traffic.

METHODS

Eleven normal (able-bodied) human subjects and 11 patients with spinal transection due to spinal cord injury (SCI) were studied. They were confined to bed for 24 h. Blood pressure and heart rate were monitored every 15 min with an automatic device and leg flow with an automatic strain-gauge plethysmograph synchronised to the pressurometer. Peripheral resistance was calculated at the same intervals.

RESULTS

In able-bodied subjects leg resistance was significantly higher during waking hours (when the sympathetic system is more activated) than during sleep, while in subjects with spinal cord injury no difference was detected between day-time and night-time.

CONCLUSIONS

The circadian rhythm is controlled by adrenergic fibres transmitted via the spinal cord.

Effects of caffeine on glucose tolerance: a placebo-controlled study

OBJECTIVE

The investigation was performed to study the effects of 200 mg oral caffeine on glucose tolerance.

DESIGN

Single-blind Latin square with active treatment (caffeine) and placebo.

SETTING

The University of Padova, Department of Internal Medicine.

SUBJECTS

30 nonsmoking healthy subjects aged 26-32 years who abstained not only from coffee but also from tea, chocolate and cola for 4 weeks and who had given their informed consent.

INTERVENTIONS

A 75 g oral glucose tolerance test (OGTT) was performed after giving caffeine or placebo (highly decaffeinated coffee).

RESULTS

The glycaemic curve was normal in all subjects and was similar in the two groups until the second hour; in subjects taking caffeine a shift towards the right was detected at the 2nd, 3rd and 4th hours in comparison to those taking the placebo. Blood insulin levels were comparable after caffeine and after placebo along the entire OGTT.

CONCLUSIONS

The data suggest that caffeine intake induces a rise in blood glucose levels that is insulin independent.

Acute effects of the oral administration of midodrine, an alpha-adrenergic agonist, on renal hemodynamics and renal function in cirrhotic patients with ascites

The effects of the acute administration of arterial vasoconstrictors on renal plasma flow (RPF) and urinary sodium excretion (UNaV) in cirrhotic patients with ascites with or without hepatorenal syndrome (HRS) are still controversial. As a consequence, vasoconstrictors are not actually used in the treatment of renal sodium retention or HRS in these patients, regardless of the several lines of evidence suggesting that these renal functional abnormalities are related to a marked arterial vasodilation. The lack of an orally available effective arterial vasoconstrictor probably represents a further reason for this omission. Consequently, the present study was made to evaluate the acute effects of the oral administration of midodrine, an orally available -mimetic drug, on systemic and renal hemodynamics and on UNaV in cirrhotic patients with ascites. Mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), systemic vascular resistance (SVR), left forearm blood flow (LFBF), left leg blood flow (LLBF), RPF, glomerular filtration rate (GFR), UNaV, plasma renin activity (PRA), plasma concentration of antidiuretic hormone (ADH), and the serum levels of nitrite and nitrate (NOx) were evaluated in 25 cirrhotic patients with ascites (17 without HRS and 8 with type 2 HRS) before and during the 6 hours following the oral administration of 15 mg of midodrine. During the first 3 hours after the drug administration, a significant increase in MAP (89.6 +/- 1.7 vs. 81.80 +/- 1.3 mm Hg; P < .0001) and SVR (1, 313.9 +/- 44.4 vs. 1,121.2 +/- 60.1 dyn . sec . cm-5; P < .0001) accompanied by a decrease in HR (69 +/- 2 vs. 77 +/- 3 bpm; P < .005) and CI (2,932.7 +/- 131.4 vs. 3,152.5 +/- 131.4 mL . min-1 . m2 BSA; P < .0025) was observed in patients without HRS. No change was observed in LFBF and LLBF. The improvement in systemic hemodynamics, which was also maintained during the the 3- to 6-hour period after midodrine administration, was accompanied by a significant increase in RPF (541.5 +/- 43.1 vs. 385.7 +/- 39.9 mL . min-1; P < .005), GFR (93.1 +/- 6.5 vs. 77.0 +/- 6.7 mL . min-1; P < .025), and UNaV (92.7 +/- 16.4 vs. 72.2 +/- 10.7 microEq . min-1; P < .025). In addition, a decrease in PRA (5.33 +/- 1.47 vs. 7.74 +/- 2.17 ng . mL-1 . h; P < .05), ADH (1.4 +/- 0.2 vs. 1.7 +/- 0.2 pg . mL-1; P < .05), and NOx (33.4 +/- 5.0 vs. 49.3 +/- 7.3 micromol-1; P < .05) was found. In patients with HRS, the effects of the drug on the systemic hemodynamics was smaller and shorter. Accordingly, regardless of a significant decrease in PRA (15.87 +/- 3.70 vs. 20.70 +/- 4.82 ng . mL-1 . h; P < .0025) in patients with HRS, no significant improvement was observed in RPF, GFR, or UNaV. In conclusion, the acute oral administration of midodrine is associated with a significant improvement in systemic hemodynamics in nonazotemic cirrhotic patients with ascites. As a result, renal perfusion and UNaV also improve in these patients. By contrast, midodrine only slightly improves systemic hemodynamics in patients with type 2 HRS, with no effect on renal hemodynamics and renal function.

Cardiovascular risk factors in the elderly

Although a number of risk factors for cardiovascular morbidity and mortality have been identified in young and middle-aged adults, their prevalence and importance are less known in the elderly. Elderly people have a risk profile different from that of younger subjects, but representative data on risk factors for cardiovascular disease in the elderly are difficult to find in the literature. Some typical 'major' risk factors, like blood pressure (BP), total cholesterol or left ventricular hypertrophy, do not have a clear predictive role for cardiovascular mortality in the elderly, especially in the extreme ages, while risk indicators usually labelled as 'minor' (serum uric acid, ventilatory function or proteinuria), do have a strong predictive value in these individuals. This must be taken into account when evaluating the cumulative risk of the elderly, in order to avoid overtreatment of subjects with mildly elevated BP or cholesterol.

Subjects with obstructive pulmonary disease tend to be chronically vasodilated

1. In 12 unselected outpatients with chronic obstructive pulmonary disease and six controls, arterial pH, PaO2, PaCO2 and oxygen saturation (SaO2), forced expiratory volume in 1.0 s (FEV1.0) and vital capacity were measured. Subjects were grouped into those with or without obstruction based on the Tiffenau index. The Baseline Dyspnoea Index was employed to objectify the severity of dyspnoea and the Borg index to evaluate the subjective sensation. Blood pressure was measured with a sphygmomanometer; calf arterial flow both at rest and during reactive hyperaemia with a plethysmograph. Basal and minimal resistance were calculated.2.FEV1.0 was 26% lower in patients with obstruction than in controls, and was also lower in patients with moderate-to-severe obstruction compared with those with mild or no obstruction. Arterial flow (75% greater in the patients with obstruction) progressively increased with increasing severity of obstruction, being 54% higher in those with mild obstruction than in those with no obstruction (P<0.001), and 28% higher in moderate-severe than in mild obstruction (P<0.005). In multiple regressions, F correlated inversely with FEV1.0, PaO2 and SaO2, and directly with PaCO2. Basal resistance correlated positively with FEV1.0, SaO2 and the Tiffenau index, and inversely with PaCO2 (r=-0.52, P=0.02). Minimal resistance was significantly lower in obstructed than in non-obstructed subjects. Both basal and minimal resistance progressively decreased, although insignificantly, with worsening bronchial obstruction. PaCO2 did not correlate with any haemodynamic parameter. Borg index correlated indirectly with FEV1.0 and basal resistance directly with arterial flow.3. Patients with chronic obstructive pulmonary disease therefore tend to show chronic vasodilatation depending on hypoxia rather than PaCO2. Other mechanisms could be involved in this phenomenon. The Borg index is a good indicator of oxygen desaturation and vasodilatation.

Should digoxin be proscribed in elderly subjects in sinus rhythm free from heart failure? A population-based study

Increased mortality in digoxin-treated subjects has been demonstrated in patients with recent myocardial infarction. Those with congestive heart failure (CHF) due to causes other than myocardial infarction seem to be free from this effect. No information is currently available concerning mortality in elderly people who are frequently prescribed digitalis even in the absence of CHF. The aim of this study was to investigate whether subjects improperly receiving digoxin were worse off than those not receiving this drug. This analysis is a part of CASTEL, a population-based prospective study that has enrolled a cohort of 2,254 subjects aged > or = 65 years. CHF was diagnosed in 187 subjects and atrial fibrillation (AF) in 90. The remaining 1,977 were free from CHF and in sinus rhythm, but 447 were treated with digitalis. Cumulative mortality and morbid events by digitalis treatment were calculated in all these categories. Among subjects free from CHF and AF (improper use), all-cause and cardiovascular mortality was significantly higher among those taking digitalis than in those who did not. Non-fatal events including CHF were also more apparent in the former than in the latter. Cox analysis confirmed digitalis as a predictor of mortality in these subjects. No effect of digitalis on survival was found in patients with CHF or AF (proper use). In elderly subjects without atrial fibrillation or CHF, the use of digitalis worsens morbidity and mortality.

Effect of octreotide on 24-h blood pressure profile in acromegaly

The aim of the study was to investigate the effect of octreotide, a somatostatin analog drug potentially able to inhibit growth hormone (GH), on the circadian blood pressure profile in a group of patients with acromegaly. Ten patients with GH-secreting pituitary adenoma were studied before and 6 months after treatment with subcutaneous octreotide 0.2 to 0.6 mg/day. Twenty-four hour blood pressure and heart rate were measured every 15 min at daytime (07:00 to 22:59) and every 30 min at nighttime (23:00 to 06:59) using a TM-2420 recorder. No correlation was found between GH levels and 24-h blood pressure in baseline conditions. Untreated patients had a significant nocturnal decrease of both systolic and diastolic blood pressure (P < .01), and all showed a circadian systolic or diastolic blood pressure rhythm. During octreotide treatment, 24 h as well as nighttime systolic and diastolic blood pressures significantly increased (P < .05), whereas daytime systolic and diastolic blood pressures did not change. Treated patients did not have a nocturnal decline in both systolic and diastolic blood pressures (P = NS), and eight lost their systolic or diastolic blood pressure rhythm. In conclusion, blood pressure circadian rhythm seems to be maintained in acromegaly. Octreotide treatment is associated with an increase of 24-h and nighttime blood pressure, and with loss of circadian blood pressure rhythm. Splanchnic vasoconstriction by this drug, shifting blood to peripheral vessels, may explain this phenomenon.

Characterisation of hypertensive patients according to 24 H peripheral resistance

To clarify whether a circadian rhythm of peripheral resistance exists in humans and whether hypertensive patients represent a homogeneous category in this respect, 15 normotensives aged 31 +/- 4 years and 30 hypertensives aged 41 +/- 13 years were confined to bed for 22 h and forearm flow recorded automatically. Night-time BP values were higher in hypertensive patients (Group B) whose night/day ratios of mean BP were below the 95% C.I. of the normal regression of the normotensives, than in those falling within the 95% C.I. (Group A). Forearm resistance was lower during sleep than during waking in Group A and in the normotensive controls, paralleling the nocturnal blood pressure fall. On the contrary, in the Group B hypertensives, despite a comparable night-time BP decrease, forearm resistance was higher during sleep than during waking.

Leg versus forearm flow: 24 h monitoring in 14 normotensive subjects and in 14 age-matched hypertensive patients confined to bed

A circadian blood pressure rhythm has been demonstrated in the majority of subjects, even if inactive during daytime. A rhythm of leg blood flow and peripheral resistance, with higher values during sleep than during waking, has also been recently shown in subjects confined to bed. Doubts still persist on whether such a rhythm also exists in the forearm, and whether or not its trend is similar to that found in the leg. In this study, leg and forearm blood flow and resistance were monitored noninvasively every 15 min for 22 h in 14 normotensives and 14 age-matched hypertensives confined to bed. A significant blood pressure fall (normotensives, -4.8%/-6.1%; hypertensives, -7.1%/-6.3%; all P <.0001), heart rate decrease (-14.9 in the former, -10% in the latter; both P <.0001) and leg flow increase (normotensives, +47.4%, hypertensives, +36.1%; both P <.0001) were found during sleep in all subjects, because of a blood redistribution probably attributable to activation of the cholinergic system. Forearm flow was significantly higher during sleep (+26.1%, P <.0001) in the normotensives, whereas in the hypertensives a slight nocturnal decrease (-1.9%) was found. In conclusion, the hypertensives had lower leg and forearm flow than the normotensives during sleep and similar during daytime. Peripheral resistance measured in the leg and in the forearm was greater in the former than in the latter, both during sleep and during waking.

Relationship of tachycardia with high blood pressure and metabolic abnormalities: a study with mixture analysis in three populations

Faster resting heart rate has been shown to be associated with a higher risk of developing hypertension and a greater incidence of cardiovascular morbidity and mortality. The aim of this study was to investigate the distribution of heart rate and its relationship with blood pressure and other cardiovascular risk factors in three populations. One European general population (Belgian study), one North American general population (Tecumseh study), and one European hypertensive population (HARVEST trial) were studied. Within each population, mixture analysis was used to investigate whether a mixture of two normal distributions explained the variance in heart rate better than a single distribution. In the men of all populations, mixture analysis identified a larger subpopulation of subjects with normal heart rate and a smaller one with fast heart rate. The subgroups with tachycardia had higher blood pressure and lipid levels than those with normal heart rate. In the populations in which they were measured, fasting insulin and postload glucose were also higher in the men with faster heart rate. A subgroup with tachycardia could also be singled out among the women from Tecumseh, but no relation between heart rate and blood pressure could be found. These findings show that in Western societies, high heart rate pertains to a distinct subgroup of subjects, who are more frequently men and exhibit the characteristic features of the insulin resistance syndrome. Sympathetic overactivity is likely to be the mechanism underlying this clinical condition.

[The prognostic indices of cancer mortality in the elderly]

Although cardiovascular disease is still the main cause of mortality and morbidity in the elderly, numerous epidemiological studies have disclosed an increased incidence of neoplastic disease in this age group over the past few years. A population of 3282 > or = 65-year-old subjects taking part in the Cardiovascular Study in the Elderly was monitored to discern whether a number of variables, already recognized as predictive factors of overall and cardiovascular mortality, could also affect neoplastic mortality. Apart from age, which was the chief risk factor for neoplastic mortality, sex, cigarette smoking, the presence of respiratory symptoms and the blood levels of some enzymes were predictors of cancer mortality. These results must nevertheless be regarded with caution as a number of non-neoplastic diseases typical of the elderly may mimic the signs and symptoms of cancer.

Blood pressure, serum cholesterol and nutritional state in Tanzania and in the Amazon: comparison with an Italian population

OBJECTIVE

To confirm that westernization of dietary habits represents a stimulus for the expression of cardiovascular risk.

DESIGN

Three representative age- and sex-matched samples of general populations of three continents were compared cross-sectionally by analysis of variance.

PARTICIPANTS

In total 1110 subjects aged 22-89 years, divided into three groups (370 from Tanzania and Uganda, 370 from the Amazonian region of Brazil, and 370 from northern Italy; 111 men and 259 women in each group).

RESULTS

The blood pressure of Africans eating a low-salt fish and vegetable' diet was lower than those of Brazilians, whose diet was based on cereals and meat, and highly urbanized Italians. The systolic blood pressure was correlated to the body mass index for all three populations, but with age only for the Brazilians and Italians. The total cholesterol level and body mass index, both of which are low among Africans, increased progressively with increasing economic level.

CONCLUSIONS

Transition from a rural to an urbanized lifestyle is accompanied by a rise in the main cardiovascular risk factors; the present data also show that environmental rather than racial factors have a crucial impact on the risk pattern of populations.

Hemodynamics following real and hypnosis-simulated phlebotomy

Forearm arterial flow was measured in 22 healthy first-time blood donors during a 300-ml. blood letting and during the subsequent recovery. Blood pressure (BP) was also taken simultaneously and forearm peripheral resistance calculated. Following a transient BP and flow increase due to tachycardia related to needle insertion, both systolic BP and flow progressively and significantly decreased, while resistance increased. In a further 22 sex- and aged-matched highly hypnotizable subjects, blood donation was simulated by means of verbal hypnotic suggestions. The BP, flow and resistance curves were similar to those obtained with the real blood letting, without any between-subject difference or group/time interaction. Mere hypnosis without suggestion of phlebotomy and the simple bed resting did not produce any effect. These results indicate that the hemodynamic changes observed during and after a blood loss are partly due to mental involvement rather than merely to the hydraulic effects of the removal of blood.

Impaired glucose tolerance and its co-variates among 2079 non-diabetic elderly subjects. Ten-year mortality and morbidity in the CASTEL study. CArdiovascular STudy in the ELderly

This study evaluated the role of impaired glucose tolerance (IGT) as a risk factor in a general population of 2079 non-diabetic elderly subjects. The 10-year cardiovascular morbidity was similar in normal and IGT subjects. Mortality was greater in IGT, but the Cox equations of the hazard rate were different in younger and older subjects: age, sex, lung function (forced expiratory volume in 1 s, FEV1), serum uric acid, IGT and proteinuria were predictors of overall mortality in the age class 65-79 years, while only the first 4 were associated with cardiovascular mortality. The same four items also predicted overall survival in subjects over 79 years old, while only age and uric acid were predictors of cardiovascular mortality. In older subjects, total cholesterol showed an inverse predictive value. Hyperuricaemia (> 6.4 mg/dl) and proteinuria did predict mortality in normal but not in IGT subjects, while reduced FEV1 (< 60% theoretical) was predictive in all. In 65-79-year old subjects IGT predicted mortality provided that FEV1 was normal, while in those 380 years old IGT was not a predictor. These interrelationships should be taken into account to better understand the factors underlying mortality.

Lower blood pressure values in blood donors?

594 blood donors were studied to define the influence of regular blood donation on blood pressure. Blood pressures were compared at the first phlebotomy performed at the Padova Blood Unit, the 13-year phlebotomy, and the median between the two. As a control population, a cohort of 594 non-donors from the same general population similar to the blood donors was studied twice at a 15-year interval. Subjects had made on average 7.3 +/- 0.4 donations at the first step, 23 +/- 0.6 at the second, and 30.9 +/- 0.7 at the last step. Unadjusted systolic blood pressure regularly and significantly increased by 1.6% from the first phlebotomy to the second one and by 2.3% from the first to third. Adjusted systolic blood pressure, on the contrary, significantly decreased by 2.1% and by 2.7% respectively. Diastolic blood pressure tended to increase insignificantly, while the adjusted one did not change at all. The increase of systolic blood pressure from the first to second step directly correlated with the number of donations, and this also applied to differences between the first and the third. When the increase in age was introduced in the multiple regression analysis, systolic blood pressure rise from the first to third step showed an inverse correlation with the number of phlebotomies. Our data render suspect the results of epidemiological investigations which took into consideration cohorts of blood donors; although these cohorts may be anagraphically representative of a general population, repeated phlebotomies introduce a bias leading to the detection of misleadingly low blood pressure values in regular blood donors.

Blood pressure and atherogenic lipoprotein profiles of fish-diet and vegetarian villagers in Tanzania: the Lugalawa study

BACKGROUND

There is evidence that populations with a high intake of fish, and specifically fish oils, are at reduced risk of cardiovascular disease. To explore the effect of fish intake, we compared two groups of Bantu villagers in Tanzania; one group live on the shores of Lake Nyasa and their diet includes large amounts of freshwater fish; the other group live in the nearby hills and have a vegetarian diet.

METHODS

We carried out a cross-sectional study of 622 fish-consuming villagers and 686 vegetarian villagers. 618 (99.4%) and 645 (94.0%), respectively, agreed to take part. Anthropometric and self-reported medical history data were collected by one local physician and a medical assistant, who also measured blood pressure and took blood samples for measurement of plasma lipids. A dietary questionnaire was administered to 25 families (about 15% of the study population) in each village.

FINDINGS

After adjustment for age, sex, and alcohol intake the fish-consuming group had lower mean blood pressure than the vegetarian group (123/72 vs 133/76 mm Hg, p < 0.001). The frequencies of definite and borderline hypertension (by WHO criteria) were lower in the fish-consuming than in the vegetarian group (2.8 vs 16.4%; 9.7 vs 22.3%, respectively). Plasma concentrations of total cholesterol (mean 3.53 [SD 1.04] vs 4.10 [1.04] mmol/L), triglycerides (0.92 [0.64] vs 1.31 [0.64] mmol/L), and lipoprotein(a) (201 [213] vs 321 [212] mg/L), were all lower (p < 0.0001) in the fish-consuming group than in the vegetarian group. The proportions of n-3 polyunsaturated fatty acids in plasma lipids were higher (p < 0.0001) in the fish-consuming group than in the vegetarian group (eicosapentaenoic acid 2.3 [1.3] vs 0.7 [0.2]%; docosapentaenoic acid 1.1 [0.4] vs 0.6 [0.3]%; docosahexaenoic acid 5.7 [1.6] vs 1.5 [1.1]%).

INTERPRETATION

In these villagers, consumption of freshwater fish (300-600 g daily) was associated with raised plasma concentrations of n-3 polyunsaturated fatty acids, lower blood pressure, and lower plasma lipid concentrations.

Left-ventricular hypertrophy in the elderly: unreliability of ECG criteria in 477 subjects aged 65 years or more. The CArdiovascular STudy in the ELderly (CASTEL)

AIM

To evaluate the diagnostic reliability of the ECG diagnosis of left-ventricular hypertrophy (LVH) in a cohort of elderly subjects taken from a general population.

PATIENTS

The 447 subjects with perfect echocardiography and ECG results of the 2,254 included in the Cardiovascular Study in the Elderly.

METHODS

Sensitivity, specificity, positive and negative predictive value of the most commonly used ECG tests of LVH were calculated versus the gold standard, echocardiography.

RESULTS

All ECG tests had a very low sensitivity. Furthermore, except for the Cornell index and (at least in the normotensives) the Minnesota code, they were not able to demonstrate the higher prevalence of LVH in elderly females in comparison to males. The predictive value of ECG was constantly higher in males than females when negative; when positive, some tests were more predictive in males, some in females, and in others, equally predictive in both sexes.

CONCLUSIONS

ECG is not a reliable method for screening LVH in elderly populations. Echocardiography and ECG give different information, and their reliability may be different if positive or negative.

Lack of influence of menopause on blood pressure and cardiovascular risk profile: a 16-year longitudinal study concerning a cohort of 568 women

OBJECTIVE

To analyse the effect of menopause on blood pressure and cardiovascular risk.

DESIGN

From an Italian general population, 568 women (408 pre- and 160 post-menopausal) were screened twice, in 1978 and 16 years later.

METHODS

Cross-sectional analyses both in 1978 and in 1994, and longitudinal analysis in the 1978-1994 period.

RESULTS

For the general analysis the cohort was reduced to 525 women with paired data in 1978 and 1994. In both cross-sectional studies, unadjusted blood pressure and cardiovascular risk were higher after than they were before menopause, but any difference disappeared after adjustment or matching for age. In 1994 we studied three groups of women: those who were still premenopausal, those who were fertile in 1978 but postmenopausal in 1994 and those who were already postmenopausal in 1978. The 16-year blood pressure increment was similar in all three groups. The incidence of myocardial infarction and angina pectoris was greater in those who were already postmenopausal than it was in those who had their menopause during the study period. An analysis of mortality was performed for all of the 568 women. Forty-three of them died, 14 from cardiovascular causes (six before and eight after menopause), 18 from neoplasia (two before and 16 after menopause) and 11 from other diseases. Menopausal status was rejected from the Cox equations both of overall and of cardiovascular mortality, showing a significantly predictive value only for neoplastic mortality.

CONCLUSION

Menopause has no influence on high blood pressure and cardiovascular risk. The greater blood pressure levels, mortality and morbidity observed in postmenopausal women are simply attributable to their older age and are no longer detectable in an age-matched sample.

24 h rhythm of blood pressure and forearm peripheral resistance in normotensive and hypertensive subjects confined to bed

OBJECTIVES

To define whether a diurnal rhythm of peripheral resistance exists in normotensive and hypertensive subjects, has any relationship with that of blood pressure and differs in dipper and non-dipper hypertensives.

DESIGN AND METHODS

Forty-three subjects (13 normotensives and 30 mild-to-moderate essential hypertensives) confined for 24 h to bed were included. Blood pressure was recorded for 22 h at 15 min intervals, plethysmographic forearm flow was simultaneously measured and forearm resistance calculated. The analysis was performed for the whole 22 h period and for three 4 h truncated periods, two of certain wakefulness and one of certain sleep.

RESULTS

A circadian rhythm of forearm resistance was shown in the normotensives, paralleling that of blood pressure. All the normotensives were dippers, with a nocturnal blood pressure dip (systolic/diastolic) of -4.5/-6.0%. In the hypertensives, the day/night blood pressure trends were not homogeneous: 21 showed higher blood pressure values during waking time, with a trend quite similar to that of the normotensives, whereas the other nine were non-dippers. Resistance was lower during sleep than during waking both in the normotensives and in the dipper hypertensives, whereas in the non-dippers it was higher during sleep.

CONCLUSIONS

A sleep/waking rhythm of peripheral resistance with the highest values during daytime and the lowest during night-time does exist in normotensive as well as in the majority of hypertensive subjects resting continuously in bed, and therefore is largely independent of physical activity. Only in a minority of hypertensive patients are higher values of peripheral resistance present during sleep.

[The reduction of respiratory function is an independent risk factor in the elderly]

The predictive value of the impairment of lung function and cigarette smoking has been evaluated in 2080 elderly subjects aged > or = 65 years included in the CASTEL (Cardiovascular Study in the Elderly). Some common risk factors, as well as forced expiratory volume, vital lung capacity, and Tiffenau index have been examined with Cox analysis. The 10-year survival equation was as follows: [formula: see text] In disagreement with other studies, in our survey smoking was not a predictor of mortality, although it was able to reduce survival by reducing respiratory function.

[Familial pheochromocytoma: a family studied for 3 generations]

A family with a very high prevalence of pheochromocytoma (62%, i.e. 100% in the 1st generation and 75% of the second one) is described. The proband was a 19-year-old woman with a 30 g right-side tumor, who died at 24 years because of a heart failure. Both sisters of the proband developed a right-side pheochromocytoma at 13 and respectively 14 years of age and are now normotensive after surgical exeresis. One of them had 3 sons: 2 with pheochromocytoma and a third one dead at 9 years of age for pulmonary oedema. Accuracy is needed in studying relation of all subjects with pheochromocytoma.

Diltiazem vs. nicardipine on ambulatory and exercise blood pressure and on peripheral hemodynamics

The present study was aimed at evaluating the antihypertensive efficacy of sustained-release diltiazem 180 mg vs. sustained-release nicardipine 40 mg both given twice daily. To this end 20 patients with mild to moderate hypertension were studied. After a two-week placebo period diltiazem and nicardipine were administered for 4 weeks according to a crossover design. To assess the antihypertensive efficacy of the two drugs all patients underwent Twenty-four-hour non-invasive blood pressure (BP) monitoring and a submaximal bicycle ergometric test. Ambulatory BP monitoring showed a tendency for systolic BP to be lower with nicardipine than with diltiazem during waking hours, while diastolic BP was lowered to the same extent by the two drugs. During sleep a slightly greater BP fall was observed with diltiazem. 24-hour spontaneous BP variability was slightly reduced with diltiazem and unchanged with nicardipine. Mean 24-hour heart rate was also unchanged with nicardipine and slightly reduced with diltiazem. Peripheral resistance measured by plethysmography significantly decreased with the former but not with the latter. BP and heart rate response to exercise was left unchanged by nicardipine and was slightly decreased by diltiazem. This study demonstrates that both sustained-release diltiazem and nicardipine are effective in controlling BP throughout the 24 hours without increasing BP variability. While the antihypertensive action of nicardipine was associated with a decrease of peripheral resistance, this was not the case with diltiazem.

[Isolated systolic hypertension: epidemiologic aspects, prevention, and risk]

Epidemiological studies have shown since long that around 20% of elderly people suffer from isolated systolic hypertension. More recently it was calculated that this condition implies a 3 fold increase in the incidence of cerebrovascular accidents and a 2.2 fold increase in the incidence of myocardial infarction. This is why more attention is now dedicated to this condition by both clinicians and research workers, especially since the recent demonstration that its treatment may lead to a reduction in morbidity and mortality from cerebrovascular causes. Unfortunately it was also shown that antihypertensive drugs are more likely to be not so well tolerated in elderly hypertensives as in adults and often worsen the quality of life. For this reason a careful selection of the patients to be submitted to treatment and a close evaluation of the hypotensive response once therapy has been started seem in order. To this end 24-hour blood pressure monitoring would seem useful as it gives more reliable information on the usual blood pressure of an individual and furthermore it allows the detection of orthostatic hypotension and of possible excessive blood pressure falls at night which are frequent causes of untoward side effects on one hand and of ischemic events on the other.

Effect of two different therapeutic approaches on total and cardiovascular mortality in a Cardiovascular Study in the Elderly (CASTEL)

Although limited numbers of elderly subjects have occasionally been included in population-based studies, only a few studies have been conducted specifically on elderly hypertensives, and practically none at a population level. We studied 655 hypertensive subjects from a cohort of 2,254 elderly subjects. The intervention consisted of the creation of a Hypertension Outpatients' Clinic under our auspices but with complete co-operation from general practitioners, randomizing the identified hypertensive patients into pre-established therapeutic drug regimens, and early follow-up recording of mortality for 7 years. The drugs used were clonidine (n = 61), nifedipine (n = 146) and the fixed combination of atenolol+chlorthalidone (n = 144); 304 subjects underwent "free therapy" by their personal physicians without any special intervention. There were 1,404 normotensive subjects. Overall 7-year follow-up mortality was 34.9% in the hypertensive subjects receiving "free therapy", 22.5% in those receiving "special care", and 24.2% in the normotensives. Cardiovascular mortality was respectively 23.7%, 12.2%, and 12.0%. Overall and cardiovascular annual cumulative mortality were significantly lower in the << special therapy >> than in the << free therapy >> group. The fixed combination of atenolol and chlorthalidone reduced mortality below that of the normotensives, independent of other cardiovascular risk factors.

Haemodynamics of recovery after strenuous exercise in physically trained hypertensive and normotensive subjects

1. Central and peripheral post-exercise haemodynamics were studied in 18 physically trained male subjects (10 hypertensive and eight normotensive) engaging in sports activities for 3-5 h/week. After a preliminary multistage bicycle ergometric test to evaluate their maximal oxygen consumption and anaerobic threshold, they underwent prolonged exercise at anaerobic threshold in the semi-supine position at 30% grade until exhaustion (mean duration 60.0 +/- 16.7 min in the normotensive subjects and 61.0 +/- 5.7 min in the hypertensive subjects, not significant). During the recovery time, intra-arterial blood pressure, echocardiographic cardiac output and indium-gallium strain-gauge plethysmographic peripheral flow were measured, and total, forearm and leg peripheral resistances were calculated respectively from mean blood pressure/cardiac output and mean blood pressure/peripheral resistance. 2. Systolic blood pressure was decreased during the entire recovery period in comparison with the baseline values (-8.4 mmHg, -43.8 mmHg and -39.7 mmHg at the 1st, 5th and 10th min in the hypertensive subjects, P = 0.001, P = 0.0001 and P = 0.0001 respectively; -18.8, -25.5 and -24.1 mmHg in the normotensive subjects, not significant, P = 0.01 and P = 0.01, respectively) without any significant difference between the two groups, whereas the reduction in diastolic blood pressure was not statistically significant. Peripheral flow increased and peripheral resistance decreased in parallel in the forearm and the leg and showed similar trends in the hypertensive subjects and the normotensive subjects. The increase in cardiac output and left ventricular ejection fraction and the decrease in total resistance were also similar in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Predictors of mortality in very old subjects aged 80 years or over

We studied 318 subjects aged 80 years of over included in the Cardiovascular Study in the Elderly (CASTEL). Some well known risk factors (left ventricular hypertrophy, glucose intolerance, cholesterol, ApoB/ApoA ratio, triglycerides, proteinuria, cigarette smoking, and ECG abnormalities), whose importance in cardiovascular risk is definitely accepted for young adults, were very poor predictors of mortality in our survey. On the contrary, FEV1 reduction and blood uric acid were strong predictors.

Mortality in relation to Minnesota code items in elderly subjects. Sex-related differences in a cardiovascular study in the elderly

The prognostic value of electrocardiographic abnormalities has not been widely studied in the elderly. We examined the Minnesota code ECG items in 2254 elderly subjects of the Cardiovascular Study in the Elderly (CASTEL), performed on an Italian general population. In our experience, codes for ischaemia, 1st-degree atrio-ventricular block, bundle branch blocks, myocardial infarction, atrial fibrillation or sinus tachycardia were predictors of overall mortality in females, while only the former three items were predictors in men. Although ischaemia, left bundle branch block and atrial fibrillation were predictors of cardiovascular mortality in both sexes, right bundle branch block, supraventricular arrhythmias and left ventricular hypertrophy were predictors only in men, and 1st-degree atrio-ventricular block were predictors only in women. Surprisingly, left anterior haemiblock and bifascicular blocks were not predictive of mortality.

Blood pressure, left ventricular hypertrophy and diabetes among 179 very old hypertensives from an Italian general population. The CASTEL (Cardiovascular Study in the Elderly)

Hypertension is common in elderly subjects, but old and particularly very old people have usually been excluded from major epidemiological trials. We studied 179 hypertensive subjects aged 80 years or more drawn from elderly people of an Italian town within the context of the CASTEL (Cardiovascular Study in the Elderly). Prevalence of hypertension declined from 66.7% (first visit, first measurement) to 56.3% (last visit, last measurement). Systolic but not diastolic blood pressure was a little higher among very old hyperglycemic hypertensive subjects than in normoglycemic ones, while left ventricular mass was independent of both blood pressure and glucose intolerance.

Unexpected effects of coffee consumption on liver enzymes

The effects of regular daily coffee consumption on liver enzymes were studied in a large number of subjects from the general population. In coffee drinkers, liver enzymes (gamma-glutamyl transferase, alanine-amino transferase, and alkaline phosphatase) and serum bilirubin were lower than in non-coffee-drinking subjects or in those consuming less than 3 cups daily. The hypothesis proposed is that liver enzymes are a target for caffeine contained in coffee.

Haemodynamic effects of coffee and purified caffeine in normal volunteers: a placebo-controlled clinical study

In order to evaluate the effects of 'espresso' Italian coffee on resting flow, blood pressure, and peripheral resistance, 15 non-coffee drinking healthy volunteers received 2 cups of regular coffee, 200 mg purified caffeine or placebo in a latin square double-blind crossover protocol. Before and 30, 60, 90 and 120 min after ingestion, segmental resting flow and BP were measured and peripheral resistance was calculated. An echocardiogram was also performed before and 60 and 120 min after caffeine intake. Both regular coffee and caffeine produced a significant decrease in resting flow and a significant increase in resistance; both systolic and diastolic BP also increased, although not significantly. No variation was observed in heart rate and in cardiac contractility. Placebo (highly decaffeinated coffee for regular coffee and china bitter extract for caffeine) did not produce any haemodynamic effect. In five other healthy volunteers used to drinking more than 5 cups of coffee a day, coffee administration had no effect. These data demonstrate that the caffeine contained in espresso Italian coffee is a vasoconstrictor agent whose effects however are completely blunted in usual coffee drinkers as a consequence of adaptation.

[Arterial hypertension, correlated factors and cardiovascular risk]

Arterial hypertension is considered one of the major risk factors for cardiovascular diseases. This is clearly demonstrated by the numerous epidemiological studies conducted in the last 30 years. More recently the attention of several investigators was centered on possible additional risk factors connected with hypertension, first of all left ventricular hypertrophy. In fact the Framingham study and other longitudinal studies have come to the conclusion that left ventricular hypertrophy represents a major risk factor, at least in men. Even more recently other research workers suggested that the activation of the renin-angiotensin system might also increase cardiovascular risk as well as a generalized increase in the Na+/H+ countertransport. If confirmed, these demonstrations could have not only physiopathological and clinical implications, but also some therapeutic consequences. In fact not all available antihypertensive agents are capable of positively interfering with these parameters.

[Atrial fibrillation in a cohort of the elderly: etiopathogenic role of occult hyperthyroidism and diagnostic and therapeutic considerations. Results of the CASTEL (CArdiovascular STudy in the ELderly)]

This work was performed in order to evaluate the weight of hyperthyroidism on the genesis of atrial fibrillation in elderly subjects. The data are from the CASTEL (CArdiovascular STudy in the ELderly), an epidemiologic study performed in a town of northern Italy (Castelfranco Veneto), whose 3088 elderly subjects were called and 2254 enrolled for a 7-year intervention trial. From 2224 elderly persons examined in the present study, 90 had atrial fibrillation (AF) as determined by the presence of Minnesota Code 8-3; the other 2134 were used as control population. In the 90 with AF and in the randomly chosen controls, the thyroid function was studied by means of the TRH-test. Taking into consideration an increase of TSH greater than 0.5 or greater than or greater than 1 muUI/ml over the basal value after TRH administration, 5.5% of subjects with atrial fibrillation had a suppressed response (i.e. hyperthyroidism); taking into consideration a peak value of TSH greater than or equal to 2.3 muUI/ml irrespective to the basal value, the prevalence of hyperthyroidism was higher (17.8%), but not different than in control subjects. In conclusion, hyperthyroidism is frequent in elderly subjects but it does not play a role in the pathophysiology of AF. On the contrary, AF may be explained in the majority of cases by concomitant cardiovascular disease, i.e. left atrial enlargement, arterial hypertension, myocardial ischemia, and heart failure.

The CASTEL project (CArdiovascular STudy in the ELderly): protocol, study design, and preliminary results of the initial survey

The CASTEL (CArdiovascular STudy in the ELderly) has been performed in order to evaluate the prevalence of hypertension of people aged 65 years or more, to evaluate the cardiovascular risk of elderly subjects from a general population, to verify the feasibility and effectiveness of a systematic continuous community-based hypertension control program in the elderly, and finally to evaluate whether a population-based therapeutic intervention was able to extend to a great number of elderly hypertensive patients the benefits of a better control of hypertension. Only the preliminary results of the initial survey are described in this paper, since the final data collection will be available at the end of 1991. The prevalence of hypertension in elderly subjects of the CASTEL was 51.2% (44.6% for males, 52.2% for females), that of isolated systolic hypertension was 8.8% among the whole population sample (2254 subjects) and 23.4% among the subgroup of 850 hypertensives screened following the WHO criteria; 8 visits were performed during the initial screening and prevalence of hypertension regularly decreased from the first visit to the last one. Taking into consideration the mean of the last 2 blood pressure measurements performed during visit 8, average systolic blood pressure was 175.5 +/- 25.9 mmHg and diastolic 93.5 +/- 13.0 mmHg. Some correlations between blood pressure and other biological parameters are also discussed.

Haemodynamic effects of coffee and caffeine in normal volunteers: a placebo-controlled clinical study

The acute haemodynamic effects of Italian coffee and 200 mg purified caffeine were investigated in 15 healthy non-coffee-drinkers compared to individuals who consumed placebo (highly decaffeinated coffee for regular coffee, and china bitter extract for caffeine). Before coffee and caffeine consumption and 30, 60, 90 and 120 min afterwards, rest flow and blood pressure were measured, and peripheral resistance in the arm was calculated; an echocardiogram was also performed before and 60 and 120 min after caffeine consumption. Both coffee and caffeine significantly decreased rest flow, and increased peripheral resistance. Systolic blood pressure increased by 10% and diastolic pressure increased by 5% for at least 2 h. No variation in heart rate or cardiac contractility was found. No effects were observed after placebo treatment. It is concluded that Italian coffee and caffeine increase blood pressure via vasoconstriction.

[Cardiovascular effects of coffee consumption in the aged: the CASTEL epidemiologic study]

The data obtained from 2240 subjects aged 65 years or more from the general population of Castelfranco Veneto (Italy) included in the CASTEL (CArdiovascular STudy in the ELderly) epidemiological Italian project were analyzed in relation to coffee consumption. Subjects were divided into 3 classes: class 1 (N = 109): non coffee drinkers; class 2 (N = 1554): 1 to 2 cups of coffee per day; class 3 (N = 577): 3 or more cups per day. The results were described by ANOVA, Tukey post hoc test and Pearson correlation coefficient with Bonferroni's conservative correction. In classes 2 and 3 total cholesterol, apolipoprotein B100 and calculated LDL-cholesterol were higher than in class 1. The number of cups of coffee per day directly correlated to both the number of cigarettes per day and the number of drinks per week. Although these data seem to indicate a convergence of risk factors (cholesterol, smoking, alcohol) in coffee drinkers, no increase in the prevalence of cardiovascular events was found in coffee drinkers in comparison with non drinkers. This could be attributed to the fact that prevalence of hypertension and diabetes did not increase with increasing coffee consumption; on the contrary, they were lower in classes 2 and 3 than in class 1.

[Hemodynamic effects of "expresso" Italian coffee and pure caffeine on healthy volunteers]

In 15 healthy non-coffee-drinker subjects and in 5 usual coffee-drinkers, the effects were studied of 2 cups of "espresso" italian coffee and of 200 mg purified caffeine on blood pressure, heart rate, forearm rest flow and peripheral resistance. In the 15 non-coffee-drinkers, left ventricular ejection fraction, fractional shortening, cardiac output and end-systolic stress were also evaluated by a 2D-guided M-mode echocardiogram before and 60 and 120 min after oral administration of 200 mg purified caffeine. In the non-coffee-drinker volunteers, diastolic and systolic blood pressure and peripheral resistance increased both after "espresso" coffee and after caffeine. In the usual drinkers no hemodynamic effect was seen. No variation of cardiac contractility was observed. We conclude that caffeine contained in the "espresso" coffee obtained with the high-pressure italian procedure is a strong vasoconstrictor agent, while it has no action on cardiac contractility.

[Agenesis of the right carotid in a subject with dextrocardia. Diagnostic imaging in 1 case with unique characteristics]

A man aged 51 with dextrocardia and right common and internal carotid artery agenesis is described. Cerebral blood flow is allowed internally by the left carotid and left vertebral antegrade flow, while right artery has only the function to drain the blood from the left side of vertebral system. A small external right carotid does exist, but it is separated from the cerebral hemodynamics. Diagnosis of dextrocardia was made on the basis of the standard chest X-ray, that of carotid agenesis on the basis of selective digital arteriography, color-Doppler and magnetic resonance. The diagnosis of congenital agenesis was based on the absence of a foramen caroticus and of a canalis caroticus. Large anasthomosis between the left and right side of cerebral system permit a normal perfusion to left cerebral hemispherium and a quite normal life.

Plethysmographic effects of doxazosin in essential hypertensive patients

In the treatment of hypertensive patients with peripheral vascular disease, alpha 1-adrenoceptor blockers may be considered first-choice drugs since they reduce the total peripheral resistance and do not decrease the plasma volume. As a preliminary step, we investigated the plethysmographic effects of doxazosin (1-8 mg for 6 weeks) on calf flow in 32 uncomplicated hypertensive patients. Despite the fall in sitting and standing blood pressure (from 163 +/- 18/101 +/- 6 to 147 +/- 19/94 +/- 8 mmHg and from 162 +/- 18/107 +/- 9 to 145 +/- 18/95 +/- 8 mmHg, respectively; both P less than 0.001) the calf flow was not decreased at rest and after ischaemia. Resting resistance was not significantly reduced (from 49.5 +/- 35 to 38.9 +/- 33 mmHg/100 ml per min) but its fall was significantly correlated with the fall in mean blood pressure (rs = 0.35, P less than 0.05). These findings confirm that doxazosin may be useful in the treatment of hypertension complicated by peripheral artery disease.