Longitudinal association of ambulatory pulse pressure with left ventricular mass and vascular hypertrophy in essential hypertension

Mutual Effect Modification between Insulin Resistance and Endothelial Dysfunction in Predicting Incident Heart Failure in Hypertensives

Insulin resistance and endothelial dysfunction are associated with heart failure (HF). Our objective was to investigate whether endothelial dysfunction and insulin resistance are independent predictors of incident HF and if a possible interaction exists between them. We enrolled 705 white never-treated hypertensives. Endothelium-dependent vasodilation was investigated by intra-arterial infusion of acetylcholine. During the follow-up [median: 117 months (range: 31-211)], we documented 223 new cases of HF (3.3 events/100 patient-years). We stratified the study population into progressors and non-progressors; progressors showed an older age and a higher prevalence of females, as well as higher mean values of baseline glucose, insulin, homeostasis model assessment (HOMA), creatinine, and high-sensitivity C-reactive protein (hs-CRP), whereas the estimated glomerular filtration rate (e-GFR) and endothelium-dependent vasodilation were lower. In the multiple Cox regression analysis, serum hs-CRP (HR = 1.362, (95% CI = 1.208-1.536), HOMA (HR = 1.293, 95% CI = 1.142-1.465), maximal acetylcholine (Ach)-stimulated forearm blood flow (FBF) (100% increment, HR = 0.807, 95% CI = 0.697-0.934), and e-GFR (10 mL/min/1.73 m2 increment, HR = 0.552, 95% CI = 0.483-0.603) maintained an independent association with incident HF. HOMA and endothelial dysfunction interact between them in a competitive manner (HR = 6.548, 95% CI = 4.034-10.629), also showing a mutual effect modification. Our findings demonstrate that both endothelial dysfunction and HOMA are independent and strong predictors of incident HF in hypertensives, these two risk factors interact between them with a competitive mechanism.

Endothelial dysfunction and C-reactive protein predict the incidence of heart failure in hypertensive patients

Aims

Endothelial dysfunction and heart failure are associated, but no prospective studies demonstrated that impaired endothelium‐dependent vasodilation predicts incident heart failure. We designed this study to test whether endothelial dysfunction is associated with incident heart failure in a group of hypertensives.

Methods and results

We enrolled 735 White never‐treated hypertensive outpatients free from heart failure, diabetes, chronic kidney disease, and previous cardiovascular events. Endothelium‐dependent vasodilation was investigated by intra‐arterial infusion of acetylcholine, and laboratory determinations were obtained by standard procedures. During the follow‐up [median 114 months (range 26–206)], there were 208 new cases of heart failure (3.1 events/100 patient‐years). Dividing the study population in progressors and non‐progressors, we observed that progressors were older, showed a higher prevalence of being female, and had a higher baseline heart rate, glucose, insulin, Homeostatic Model Assessment (HOMA), creatinine, and high‐sensitivity C‐reactive protein (hs‐CRP) mean values, while estimated glomerular filtration rate and maximal acetylcholine‐stimulated forearm blood flow were lower. In the multiple Cox regression analysis, female gender [hazard ratio (HR) = 1.454, 95% CI = 1.067–1.981], fasting glucose (HR = 1.186, 95% CI = 1.038–1.357), hs‐CRP (HR = 1.162, 95% CI = 1.072–1.259), HOMA (HR = 1.124, 95% CI = 1.037–1.219), acetylcholine‐stimulated forearm blood flow (HR = 0.779, 95% CI = 0.695–0.874), and estimated glomerular filtration rate (HR = 0.767, 95% CI = 0.693–0.849) maintained an independent association with the outcome. Successively, testing the interaction between forearm blood flow and hs‐CRP, we observed that patients who have hs‐CRP values above the median and forearm blood flow under the median show a higher risk of developing heart failure (HR = 7.699, 95% CI = 4.407–13.451).

Conclusions

The present data demonstrate that an impaired endothelium‐dependent vasodilation and hs‐CRP predict development of incident heart failure in hypertensives.

Associations of maternal ozone exposures during pregnancy with maternal blood pressure and risk of hypertensive disorders of pregnancy: A birth cohort study in Guangzhou, China

Although studies have assessed the associations of maternal exposure to ozone (O₃) during pregnancy with blood pressure and the risk of hypertensive disorders of pregnancy (HDP), the results were inconsistent. Furthermore, no studies have been conducted in China where the ambient O₃ concentration continuedly increased. The present study aimed to estimate the effects of maternal exposure to O₃ during pregnancy on the HDP risk, systolic blood pressure (SBP), diastolic blood pressure (DBP) and pulse pressure (PP). All participants of pregnant women were selected from the prospective birth cohort study on Prenatal Environments and Offspring Health conducted in Guangzhou, China. A spatiotemporal land-use-regression model was used to estimate individual monthly air pollution exposure from three months before pregnancy to childbirth date. Information on HDP, SBP, DBP and PP was obtained from maternal medical records. A Logistic regression model and a mixed linear model were used to estimate the associations of maternal exposure to O₃ with the risk of HDP and blood pressure (SBP, DBP and PP), respectively. We found significant associations of maternal exposure to O₃ during the third (OR = 1.31, 95%CI: 1.07, 1.60) and the second month (OR = 1.25, 95%CI: 1.02, 1.51) before pregnancy with the risk of HDP. Observed significantly positive associations of O₃ exposures with SBP, DBP and PP during the two months before pregnancy and during the early pregnancy. The peak effects of O₃ exposure on SBP, DBP and PP were respectively observed during the second month of pregnancy (β = 1.07  mmHg, 95%CI: 0.84, 1.31  mmHg), the first month before pregnancy (β = 0.40  mmHg, 95%CI: 0.21, 0.50  mmHg) and the second month of pregnancy (β = 0.78  mmHg, 95%CI: 0.59, 0.97  mmHg). Our results suggest that maternal exposure to O₃ were positively associated with blood pressure and the risk of HDP, and the period from three months before pregnancy to the first trimester might be the critical exposure window.

Relationship between transesophageal echocardiography-derived pulmonary artery systolic pressure measurements and early morbidity in patients undergoing coronary artery bypass grafting

Context:

We studied the relationship between intraoperative transesophageal echocardiography-derived (TEE-derived) pulmonary artery systolic pressure (PASP) measurements with early morbidity in on-pump coronary artery bypass grafting (CABG) surgery.

Aims:

The objective of the study was to assess whether TEE-derived elevated PASP is independently predictive of significant morbidity.

Settings and Design:

Prospective observational study in a university hospital.

Materials and Methods:

Around 54 patients who underwent CABG under cardiopulmonary bypass (CPB) were divided into two groups; with PASP ≥35 mmHg and PASP <35 mmHg, assessed by intraoperative TEE. Outcomes studied were poor coronary revascularization, postoperative arrhythmias, myocardial infarction, respiratory failure, intra-aortic balloon pump use, pacemaker dependence, significant inotrope use, prolonged intensive care unit stay, and the total length of stay in the hospital. Mortality analysis was not a part of this study since expected sample sizes were low.

Results:

Patients with PASP ≥35 mmHg had a higher risk of respiratory failure, increased inotrope use and prolonged hospital stay, although multivariate analysis failed to demonstrate an independent association of PASP with these outcomes. Diabetes mellitus (DM), peripheral vascular disease, low cardiac output and elevated mitral annular E/e’ ratio were significantly associated with higher pulmonary arterial pressures. Multivariate analysis showed that PASP was independently associated with higher mitral annular E/e’ ratio.

Conclusions:

Our study, therefore, suggests that higher PASP may predict higher left ventricular filling pressures, and although elevated PASP ≥35 mmHg may be associated with DM; peripheral vascular disease, lower intraoperative cardiac output, postoperative respiratory failure, higher inotrope use, and delayed hospital discharge, it is not an independent predictor of any of these variables.

Association Between Intra-arterial Invasive Central and Peripheral Blood Pressure and Endothelial Function (Assessed by Flow-Mediated Dilatation) in Stable Coronary Artery Disease

BACKGROUND

Endothelial function is an independent predictor of coronary artery disease (CAD) and is regulated by a number of factors, including blood pressure.

OBJECTIVES

The current study was designed to test the hypothesis that intra-arterial invasive central blood pressure is strongly associated with endothelial function in patients with CAD.

METHODS

In patient with CAD (diameter stenosis ≥30%), invasive central (aortic) and left peripheral (brachial) blood pressures were determined during transradial coronary angiography. The endothelial function was evaluated by way of flow-mediated dilatation (FMD) of the brachial artery.

RESULTS

We enrolled 413 consecutive patients. There were 260 patients with significant CAD (sCAD, diameter stenosis ≥50%) and 153 patients with nonsignificant CAD (nsCAD, diameter stenosis <50% and ≤30%). FMD was significantly and inversely correlated with central and peripheral parameters in terms of systolic blood pressure, mean arterial pressure, and pulse pressure (PP) (r = -0.332, r = -0.184, and r = -0.407, respectively, all P < 0.001) and (r = -0.303, r = -0.190, and r = -0.319, respectively, all P < 0.001). Compared with sCAD, there was closer correlation between central PP with FMD in nsCAD (r = -0.548 vs. r = -0.345, both P < 0.001). After adjusting potential confounders such as age, body mass index and high-sensitivity C-reactive protein, multivariate analysis showed that FMD remained independently associated with central PP, degree of coronary artery stenosis, and brachial-ankle pulse wave velocity in all patients. In patients with nsCAD, the multivariate analysis showed that only central PP was independently correlated with FMD.

CONCLUSIONS

In patients with stable CAD, a decline in endothelial function is most closely associated with invasive central pulse pressure.

Relationships between blood pressure measurements and target organ damage: Data from the Korea women's chest pain registry

This study was performed to investigate the association between four BP measurements (systolic blood pressure [SBP], diastolic blood pressure [DBP], mean arterial pressure [MAP], and pulse pressure [PP]) and four TOD parameters (left ventricular mass index [LVMI], E/e', estimated glomerular filtration rate [eGFR], and obstructive coronary artery disease [CAD]). Data were obtained from a nation-wide registry, composed of 652 patients (471 women, 58.4 ± 10.5 years) with suspected CAD who underwent elective invasive coronary angiography (CAG). A total of 217 patients (33.2%) had obstructive CAD (≥50%). In multivariable analyses, E/e' was associated with SBP, MAP and PP, and CAD was associated with SBP and PP (P < 0.05 for each). All four BP measurements were not associated with LVMI and eGFR (P > 0.05 for each). In patients undergoing elective invasive CAG, SBP, and PP had stronger relationships with E/e' and CAD than DBP and MAP.

Propofol Versus Thiopental for Rapid-Sequence Induction in Isolated Systolic Hypertensive Patients: A Factorial Randomized Double-Blind Clinical Trial

Objective

We investigated the effects of four different anaesthesia induction protocols on the haemodynamic response to laryngoscopy and tracheal intubation during rapid-sequence induction (RSI) in systolic hypertensive patients.

Methods

One hundred and twenty hypertensive adult patients (systolic pressure >140 mmHg and diastolic pressure <90 mmHg), classified according to the American Association of Anesthesiologists as Class II and III were randomized into four groups. After pre-oxygenation for 3 minutes, induction and tracheal intubation were performed by blinded investigators, who also scored the intubation. Study groups composed of 30 patients each received lidocaine 1 mg kg^-1+thiopental 5 mg kg^-1 or remifentanil 1 μg kg^-1+thiopental 5 mg kg^-1 or lidocaine 1 mg kg^-1+propofol 2 mg kg^-1 or remifentanil 1 μg kg^-1+propofol 2 mg kg^-1. Succinylcholine was the muscle relaxant. Haemodynamic data were obtained before (baseline) and after induction, at intubation, and at 1, 3, 5 and 10 minutes after intubation. A rise or drop in the arterial blood pressure and heart rate >20% were considered to be significant.

Results

Patients receiving remifentanil+propofol had a reduction in the systolic and mean blood pressure >20% when compared to patients receiving remifentanil and thiopental: systolic values were 125±27 mmHg in the remifentanil+propofol group versus 153±35 mmHg in the remifentanil+thiopental group 1 minute after intubation (p<0.01); the mean arterial pressure values were 87±18 mmHg in the remifentanil+propofol group versus 105±25 mmHg in the remifentanil+thiopental group 1 minute after intubation (p<0.05).

Conclusion

Propofol was not superior to thiopental for the attenuation of the response to laryngoscopy and intubation during RSI in systolic hypertensive patients, whereas propofol+remifentanil combination appears to be so in terms of the heart rate stability.

Relationship of Hypertension to Coronary Atherosclerosis and Cardiac Events in Patients With Coronary Computed Tomographic Angiography

Hypertension is an atherosclerosis factor and is associated with cardiovascular risk. We investigated the relationship between hypertension and the presence, extent, and severity of coronary atherosclerosis in coronary computed tomographic angiography and cardiac events risk. Of 17 181 patients enrolled in the CONFIRM registry (Coronary CT Angiography Evaluation for Clinical Outcomes: An International Multicenter Registry) who underwent ≥64-detector row coronary computed tomographic angiography, we identified 14 803 patients without known coronary artery disease. Of these, 1434 hypertensive patients were matched to 1434 patients without hypertension. Major adverse cardiac events risk of hypertension and non-hypertensive patients was evaluated with Cox proportional hazards models. The prognostic associations between hypertension and no-hypertension with increasing degree of coronary stenosis severity (nonobstructive or obstructive ≥50%) and extent of coronary artery disease (segment involvement score of 1-5, >5) was also assessed. Hypertension patients less commonly had no coronary atherosclerosis and more commonly had nonobstructive and 1-, 2-, and 3-vessel disease than the no-hypertension group. During a mean follow-up of 5.2±1.2 years, 180 patients experienced cardiac events, with 104 (2.0%) occurring in the hypertension group and 76 (1.5%) occurring in the no-hypertension group (hazard ratios, 1.4; 95% confidence intervals, 1.0-1.9). Compared with no-hypertension patients without coronary atherosclerosis, hypertension patients with no coronary atherosclerosis and obstructive coronary disease tended to have higher risk of cardiac events. Similar trends were observed with respect to extent of coronary artery disease. Compared with no-hypertension patients, hypertensive patients have increased presence, extent, and severity of coronary atherosclerosis and tend to have an increase in major adverse cardiac events.

Ambulatory versus clinic blood pressure in predicting overall subclinical target organ damage progression in essential hypertensive patients: a 3-year follow-up study

BACKGROUND

Ambulatory blood pressure (BP) was shown to predict specific subclinical target organ damage (TOD) progression better than clinic BP, whereas the usefulness of ambulatory and clinic BP measurements to predict overall TOD progression is not well established.

METHODS AND RESULTS

Clinic and 24-h ambulatory BP values were obtained in 280 patients on baseline. A total of 199 participants (mean age 62.5±9.5, 59.3% men) were followed up for an average of 39 months and overall subclinical TOD were recorded at the end of follow-up period. Patients with increased TOD number had higher baseline clinic, 24-h, day and night systolic blood pressure (SBP), and pulse pressure, but baseline ambulatory and clinic diastolic blood pressure showed no differences. Multiple logistic regression analysis showed that the independent predictors of the overall TOD number increased were clinic [relative ratio (RR)=1.023, P=0.006], 24-h (RR=1.034, P=0.005), day (RR=1.023, P=0.04) and night (RR=1.038, P=0.001) SBP, as well as 24-h (RR=1.050, P=0.005), day (RR=1.037, P=0.02) and night (RR=1.062, P=0.001) ambulatory pulse pressure, and night average diastolic blood pressure with boundary correlation (RR=1.034, P=0.048). The night-time SBP value was more strongly associated with the risk of overall increased TOD number than the daytime (RR=1.049, P=0.003) or clinic SBP (RR=1.026, P=0.02). Similarly, 24-h pulse pressure was superior to clinic (RR=1.045, P=0.02) and night-time was superior to daytime pulse pressure (RR=1.104, P=0.002).

CONCLUSION

The risk of overall subclinical TOD progression increased more with a given increase in baseline ambulatory night-time BP than baseline clinic or daytime BP in essential hypertension.

Hypertension in chronic kidney disease: role of ambulatory blood pressure monitoring

Children with chronic kidney disease have a markedly increased risk of cardiovascular morbidity and children with end stage renal disease have an estimated 30 times greater risk of cardiovascular mortality than the general pediatric population. In adults, the link between hypertension and cardiovascular disease is well-documented but that association has not been so readily apparent in children with chronic kidney disease. This may be in part because the early changes in blood pressure that occur in these patients do not necessarily manifest with changes in casual blood pressure measurements. Ambulatory blood pressure monitoring, with its ability to gather multiple readings both during the normal activities of the day and the night, is felt to be a more veritable measure of blood pressure. Its use in children has been hampered by limited data on normative values and difficulties in blood pressure classification, while its use in adults is ever expanding. However, with an increasing number of studies in children with chronic kidney disease, ambulatory blood pressure has revealed a greater prevalence of abnormal findings in this population and has been shown to better predict cardiovascular risk than current standards. Two large multi-center studies in Europe and North America have revealed even greater utility of ambulatory blood pressure measures in this population. It is hoped that continued use of ambulatory monitoring in children will help overcome some of its perceived limitations while also validating its use in those at high risk of cardiovascular morbidity.

Improving detection of hypertension in girls with turner syndrome using ambulatory blood pressure monitoring

BACKGROUND/AIMS

Turner syndrome (TS) is associated with increased mortality due to cardiovascular disease and a dramatically higher rate of aortic dissection. The recognition and treatment of hypertension in this population is critical. We sought to assess the ability to detect blood pressure (BP) abnormalities comparing ambulatory blood pressure monitoring (ABPM) with conventional BP measurement methods. We hypothesized that ABPM would improve detection of hypertension and alter management strategies.

METHODS

Twenty-three girls with TS underwent BP measurements using an automated oscillometric method and a manual mercury sphygmomanometer. Twenty-four-hour ABPM was performed (Spacelabs 90217, Issaquah, Wash., USA). BP values were compared to normative data based on height and sex for ABPM, and for age, height and sex for automated oscillometric and manual measurements.

RESULTS

Five (22%) subjects were found to have ambulatory hypertension (3 of these with severe hypertension). Three subjects had prehypertension using ABPM measurements. Only 1 of the 5 patients with ambulatory hypertension was categorized as hypertensive using manual BP measurements. Twelve subjects (52%) had nocturnal hypertension. ABPM data led to a change in medical management of hypertensive patients with initiation of antihypertensive therapy.

CONCLUSIONS

ABPM is advantageous in TS, as it improves detection of hypertension, identifies those with non-dipping BP patterns, and changes medical management of patients.

Association between central obesity and circadian parameters of blood pressure from the korean ambulatory blood pressure monitoring registry: Kor-ABP registry

Central obesity has been reported as a risk for atherosclerosis and metabolic syndrome. The influence of central obesity on diurnal blood pressure (BP) has not been established. In this study, we investigated the influence of central obesity on the circadian parameters of BP by 24 hr ambulatory BP monitoring. Total 1,290 subjects were enrolled from the Korean Ambulatory BP registry. Central obesity was defined as having a waist circumference≥90 cm in males and ≥85 cm in females. The central-obese group had higher daytime systolic BP (SBP), nighttime SBP and diastolic BP (DBP) than the non-obese group (all, P<0.001). There were no differences in nocturnal dipping (ND) patterns between the groups. Female participants showed a higher BP mean difference (MD) than male participants with concerns of central obesity (daytime SBP MD 5.28 vs 4.27, nighttime SBP MD 6.48 vs 2.72) and wider pulse pressure (PP). Central obesity within the elderly (≥65 yr) also showed a higher BP MD than within the younger group (daytime SBP MD 8.23 vs 3.87, daytime DBP 4.10 vs 1.59). In conclusion, central obesity has no influence on nocturnal dipping patterns. However, higher SBP and wider PP are associated with central obesity, which is accentuated in women.

Blood pressure variables and prevalent electrocardiographic left ventricular hypertrophy in sub-Saharan African individuals with type 2 diabetes

BACKGROUND

The aim of the present study was to investigate whether brachial blood pressure (BP) variables (systolic BP [SBP], diastolic BP [DBP], pulse [PP] and mean arterial pressure [MAP]) are similar determinants of prevalent electrocardiographic left ventricular hypertrophy (LVH) in sub-Saharan Africans with type 2 diabetes (T2D).

METHODS

The study included 420 individuals (49% men) with T2D who were receiving chronic care in two main referral centers in the two major cities (Douala and Yaounde) of Cameroon. Logistic regression models were used to estimate the odds ratio (OR) and 95% confidence intervals (CI) for a standard deviation (SD) higher level of SBP (25 mmHg), DBP (13), PP (18) and MAP (20) with the risk of LVH. Discrimination was assessed and compared with c-statistics and relative integrated discrimination improvement (RIDI; %).

RESULTS

The multivariable adjusted OR (95% CI) for prevalent LVH with each SD higher pressure variable was 1.61 (1.22-2.11) for SBP, 1.27 (0.99-1.63) for DBP, 1.62 (1.23-2.15) for PP and 1.44 (1.11-1.87) for MAP. Comparison of c-statistics revealed no difference in the discrimination power of models with each of the BP variables (P > 0.09). However, RIDI showed enhanced discrimination in the models when other BP variables were replaced with PP. However, this enhancement was marginal for SBP. Using BP combinations modestly improved discrimination.

CONCLUSIONS

The best predictors of prevalent LVH in the present study population were PP and SBP, whereas DBP was the least effective predictor. These findings have implications for cardiovascular risk stratification and monitoring of risk-reducing therapies.

Increasing the validity and efficiency of blood pressure estimates using ambulatory and clinic measurements and modern missing data methods

BACKGROUND

Ambulatory blood pressure monitoring (ABPM) is considered the gold standard for BP measurement, compared to clinic BP measurements (CBP), which are a less valid predictor of target organ damage and cardiovascular events. However, ABPM is considerably more expensive than CBP, leaving BP researchers with a difficult dilemma: Use the less efficient CBP measure, or bear the cost of the more expensive ABPM. Recent developments in missing data methods, notably the two-method measurement (TMM) design, address this problem. With the TMM design, all research participants receive the less expensive CBP measure, but only a random subset receives the more expensive ABPM. The total number of participants must be increased, with additional participants receiving only CBP measurements. Even so, the TMM still reduces costs.

METHODS

We applied the TMM approach, which makes use of a "bias correction" structural equation model, to an empirical data set in which data were available for ABPM and CBP, as well as an echocardiographic measure of left ventricular mass (LVM).

RESULTS

Based on an estimated fivefold difference in cost for using ABPM compared to CBP, we found that statistical power can be considerably increased, or that BP measurement costs can be considerably reduced, when using this planned missing data design.

CONCLUSIONS

These benefits were observed with no loss of predictive validity (i.e., the observed association between BP and LVM). This suggests that the TMM design is a promising technique that in some studies may be able to decrease costs and/or increase one's power to detect effects.

eNOS and caveolin-1 gene polymorphisms interaction and intima media thickness: a proof of concept study in ESRD patients

BACKGROUND

Caveolae are a prominent microdomain in endothelial cells and appropriate localization in caveolae is fundamental for endothelial nitric oxide synthase (eNOS) activity. Since the Glu298Asp variant in the eNOS gene alters caveolar localization of the corresponding enzyme, we tested the interaction between this variant and the rs4730751 polymorphism of the caveolin-1 (CAV-1) gene as related to arterial remodeling in end-stage renal disease (ESRD) patients.

METHODS

One hundred and thirty-three ethnically homogeneous ESRD patients underwent carotid ultrasonographic studies to measure intima-media thickness (IMT) and carotid cross-sectional area (CSA). Genotyping was performed by high-throughput allelic discrimination assays on real-time PCR.

RESULTS

Arterial remodeling was associated to the number of G alleles of CAV-1 polymorphism, GG homozygotes displaying an IMT and a CSA that were, respectively, 16% and 21% higher than those in patients without the risk allele (P < 0.012). In multiple linear regression analyses including the CAV-1 and the eNOS polymorphisms and adjusting for classical risk factors and risk factors peculiar to ESRD both polymorphisms were independent correlates of IMT (CAV-1: β = 0.20, P = 0.01; eNOS β = 0.25, P = 0.001) and CSA (CAV-1: β = 0.20, P = 0.01: eNOS β = 0.13, P = 0.09). Furthermore, strong interactions emerged between the two polymorphisms for explaining the variability in IMT (P = 0.001) and in CSA (P = 0.038) in these patients.

CONCLUSION

Overall these findings form preliminary evidence that disturbed interaction between CAV-1 and eNOS may be of relevance for arterial disease in ESRD and perhaps in other human diseases.

The relationship between ambulatory arterial stiffness index and blood pressure variability in hypertensive patients

BACKGROUND AND OBJECTIVES

Ambulatory arterial stiffness index (AASI) is well known as a predictor of cardiovascular mortality in hypertensive patients. Mathematically, AASI reflect the standard deviation (SD) of blood pressure (BP) variation. AASI is measured higher levels in non-dipper than dipper. Thus, AASI has a possibility of not only reflecting arterial stiffness but also BP variability and/or autonomic nervous dysfunction.

SUBJECTS AND METHODS

Consecutive data from 418 untreated hypertensive patients were analyzed retrospectively. We examined the association between the 24-hour ambulatory BP monitoring (ABPM) parameters and AASI.

RESULTS

AASI had a simple correlation with age (R=0.189, p<0.001), relative wall thickness (RWT) (R=0.115, p=0.019), left ventricular mass index (LVMI) (R=0.192, p<0.001), average systolic BP (SBP) (R=0.232, p<0.001), average pulse pressure (PP) (R=0.363, p<0.001), SD of diastolic BP (DBP) (R=-0.352, p<0.001), SD of PP (R=0.330, p<0.001), SD of heart rate (HR) (R=-0.268, p<0.001), and nocturnal dipping (R=-0.137, p=0.005). In multiple linear regression analysis model including clinical parameters and 24 hour-ABPM parameters, independent predictors of AASI were SD of PP (β=1.246, p<0.001), SD of DBP (β=-1.067, p<0.001), SD of SBP (β=-0.197, p<0.001), and non-dipper (β=0.054, p=0.033).

CONCLUSION

AASI is closely correlated with BP variability. The result of this study shows that AASI is not only a parameter for arterial stiffness, but also a parameter for BP variability.

Circulating insulin-like growth factor-1 and its binding protein-3: metabolic and genetic correlates in the community

OBJECTIVE

The metabolic and genetic correlates of circulating insulin-like growth factor-1 (IGF-1) and its main circulating carrier, IGF-1-binding-protein-3 (IGFBP-3), are unclear.

METHODS AND RESULTS

We measured serum IGF-1 and IGFBP-3 concentrations in a sample of the Framingham Heart Study (N=3977, aged 40+/-9 years, 46% male) and evaluated their relations to cardiovascular risk factors using multivariable regression. Serum IGF-1 was inversely correlated with age, body mass index, total cholesterol, the presence of diabetes, alcohol consumption, and glomerular filtration rate (all P<0.01), whereas the ratio of IGF-1:IGFBP-3 was lower in women and inversely related to age, triglycerides, high-density lipoprotein cholesterol, systolic blood pressure, and alcohol consumption (all P<0.0001). Circulating IGF-1 correlated negatively with insulin resistance (homeostatic model assessment) (r=-0.1; P<0.0001) and was lower in participants with more components of the metabolic syndrome (Adult Treatment Panel III criteria) (P<0.0001). Additive genetic factors (heritability) accounted for 43% and 39% of the variation of IGF-1 and IGFBP-3, respectively (both P<10(-27)).

CONCLUSIONS

Our cross-sectional observations in a large community-based sample link lower circulating IGF-1 to greater metabolic risk burden and underscore substantial genetic influences on IGF-1 concentrations. Prospective studies are warranted to elucidate whether lower IGF-1 concentrations predict greater metabolic risk longitudinally.

Size, shape, and stamina: the impact of left ventricular geometry on exercise capacity

Although several studies have examined the cardiac functional determinants of exercise capacity, few have investigated the effects of structural remodeling. The current study evaluated the association between cardiac geometry and exercise capacity. Subjects with ejection fraction > or = 50% and no valvular disease, myocardial ischemia, or arrhythmias were identified from a large prospective exercise echocardiography database. Left ventricular mass index and relative wall thickness were used to classify geometry into normal, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy. All of the subjects underwent symptom-limited treadmill exercise according to standard Bruce protocol. Maximal exercise tolerance was measured in metabolic equivalents. Of 366 (60+/-14 years; 57% male) subjects, 166 (45%) had normal geometry, 106 (29%) had concentric remodeling, 40 (11%) had eccentric hypertrophy, and 54 (15%) had concentric hypertrophy. Geometry was related to exercise capacity: in descending order, the maximum achieved metabolic equivalents were 9.9+/-2.8 in normal, 8.9+/-2.6 in concentric remodeling, 8.6+/-3.1 in eccentric hypertrophy, and 8.0+/-2.7 in concentric hypertrophy (all P<0.02 versus normal). Left ventricular mass index and relative wall thickness were negatively correlated with exercise tolerance in metabolic equivalents (r=-0.14; P=0.009 and r=-0.21; P<0.001, respectively). Augmentation of heart rate and ejection fraction with exercise were blunted in concentric hypertrophy compared with normal, even after adjusting for medications. In conclusion, the pattern of ventricular remodeling is related to exercise capacity among low-risk adults. Subjects with concentric hypertrophy display the greatest limitation, and this is related to reduced systolic and chronotropic reserve. Reverse remodeling strategies may prevent or treat functional decline in patients with structural heart disease.

Impact of C-reactive protein and pulse pressure evaluated at the start of peritoneal dialysis on cardiovascular events in the course of treatment with peritoneal dialysis

BACKGROUND

Despite a reduced number of infectious complications, cardiovascular (CV) mortality remains unchanged in peritoneal dialysis (PD) patients. The aim of this study was to evaluate the effects of high-sensitivity C-reactive protein (hs-CRP) and pulse pressure (PP) at the start of PD on the development of CV events (CVEs) in these patients.

METHODS

The study population was comprised of 291 patients that started PD between January 2003 and June 2008 and were treated for more than 6 months. Baseline clinical, biochemical, and echocardiographic data, indices of dialysis adequacy, and peritoneal transport rate were reviewed retrospectively. The clinical outcome was the occurrence of a CVE.

RESULTS

Mean duration of follow-up was 28 (range 6 - 70) months. A CVE was observed in 33 patients (11.3%). The 1-, 3-, and 5-year cumulative incidences of CVEs were 4.0%, 13.7%, and 27.5%, respectively. Although multiple variables were correlated with the prevalence of a CVE in the univariate analysis, hs-CRP, PP, and comorbidity remained significant after adjustment: hs-CRP: odds ratio (OR) 4.09 (1.53 - 10.95), p = 0.005; PP: OR 2.79 (1.26 - 6.17), p = 0.012. PP and hs-CRP, which were not intercorrelated in our data, combined adversely to increase the incidence of CVEs. The incidence of CVEs increased with the number of risk factors, which included high hs-CRP, high PP, and the presence of comorbidity (no risk factor, 0%; 1 risk factor, 1.5%; 2 risk factors, 30.8%; 3 risk factors, 53.9%).

CONCLUSIONS

Our study suggests that measurements of hs-CRP and PP at the start of PD may be helpful in predicting the development of CVEs in the course of treatment with PD.

Age-associated increases in pulmonary artery systolic pressure in the general population

BACKGROUND

In contrast to the wealth of data on isolated systolic hypertension involving the systemic circulation in the elderly, much less is known about age-related change in pulmonary artery systolic pressure (PASP) and its prognostic impact in the general population. We sought to define the relationship between PASP and age, to evaluate which factors influence PASP, and to determine whether PASP is independently predictive of mortality in the community.

METHODS AND RESULTS

A random sample of the Olmsted County, Minn, general population (n=2042) underwent echocardiography and spirometry and was followed up for a median of 9 years. PASP was measured from the tricuspid regurgitation velocity. Left ventricular diastolic pressure was estimated with Doppler echocardiography (E/e' ratio), and arterial stiffening was assessed from the brachial artery pulse pressure. Among 1413 subjects (69%) with measurable PASP (age, 63+/-11 years; 43% male), median PASP was 26 mm Hg (25th to 75th percentile, 24 to 30 mm Hg) and increased with age (r=0.31, P<0.001). Independent predictors of PASP were age, pulse pressure, and mitral E/e' (all P< or =0.003). Increasing PASP was associated with higher mortality (hazard ratio, 2.73 per 10 mm Hg; P<0.001). In subjects without cardiopulmonary disease (any heart failure, coronary artery disease, hypertension, diabetes mellitus, or chronic obstructive lung disease), the age-adjusted hazard ratio was 2.74 per 10 mm Hg (P=0.016).

CONCLUSIONS

We provide the first population-based evidence of age-related increase in pulmonary artery pressure, its association with increasing left heart diastolic pressures and systemic vascular stiffening, and its negative impact on survival. Pulmonary artery pressure may serve as a novel cardiovascular risk factor and potential therapeutic target.

Postchallenge plasma glucose and glycemic spikes are associated with pulse pressure in patients with impaired glucose tolerance and essential hypertension

Elevated pulse pressure (PP) is associated with an increased risk of cardiovascular events. We examined whether PP is associated with post-challenge hyperglycemia in Japanese patients with essential hypertension and impaired glucose tolerance (IGT). In a total of 70 untreated essential hypertensive patients (age: 57+/-4 years, mean+/-SD; males=35, females=35), 24-h ambulatory blood pressure (ABP) monitoring, 75 g oral glucose tolerance testing (OGTT), metabolic analysis and echocardiography were performed. Patients were categorized into a high PP group (PP>or=60 mmHg, n=33) or a normal PP group (PP<60 mmHg, n=37). In all patients, 24-h systolic ABP, daytime systolic ABP, nighttime systolic ABP, and nighttime heart rate were significantly higher in the high PP group. Additionally, fasting immunoreactive insulin (F-IRI), homeostasis model assessment (HOMA) index, left ventricular mass index (LVMI) were also elevated in the high PP group. Finally, the high PP group exhibited impaired insulin secretion, increased post-challenge glucose concentrations and greater glucose spikes (PGS) during 75 g OGTT. Of the parameters measured, 24-h PP correlated positively with age, triglyceride, uric acid, F-IRI, HOMA index, 1-h postload glucose and insulin, 2-h postload glucose and insulin, PGS60, PGS120, PGSmax, LVMI, and deceleration time but correlated negatively with HDL-cholesterol and E/A ratio. Multiple regression analysis revealed that PP level was independently predicted by age, LVMI, and PGS120. Our results show that age, LVMI, and PGS120 are significantly associated with high PP in Japanese patients with IGT and essential hypertension.

Rate of atherosclerotic plaque formation predicts cardiovascular events in ESRD

Carotid intima media thickness (IMT) is a strong, independent predictor of cardiovascular events in both the general population and among those with end-stage renal disease (ESRD), but it is unknown whether changes in IMT or other ultrasound-measured indicators of atherosclerosis over time provide additional prognostic information. The progression of atherosclerosis with carotid ultrasound was followed in a cohort of 135 ESRD patients, 103 of whom had a repeat ultrasound after 15 mo of follow-up. The number of plaques and the proportion of patients with severe atherosclerosis increased substantially during the follow-up period, but IMT, common carotid artery diameter, common carotid artery wall-to-lumen ratio, and cross-sectional area, did not change. The rate of formation of new plaques was a strong, independent predictor of incident cardiovascular events, even after adjusting for baseline plaque burden and other potential confounders. New plaque formation over time was independently predicted by background plaque burden and serum C-reactive protein (P = 0.004 and P = 0.02, respectively). Changes in IMT and the other ultrasound-measured indicators of atherosclerosis progression did not predict cardiovascular outcomes. Therefore, monitoring IMT over time is unlikely to provide additional prognostic information compared with a single measurement, but longitudinal ultrasound monitoring of plaque formation may be useful for cardiovascular risk stratification in the ESRD population.

The contribution of familial and heritable risks in heart failure

PURPOSE OF REVIEW

The purpose of this review is to summarize the recent literature regarding the familial heritability of heart failure and to discuss the possible mechanisms through which this risk is mediated.

RECENT FINDINGS

Data from the Framingham Heart Study recently showed that the parental occurrence of heart failure increases the risk of heart failure in offspring. Although the mechanisms mediating this increased risk are not elucidated, heritable risks of heart failure may result from genes affecting the cardiac or vascular systems. Alternatively, familial risk may be mediated partly through the inheritance of recognized or as yet unidentified risk factors for heart failure. Heritable components or genetic loci for quantitative traits contribute to the development of hypertension, coronary artery disease, cardiomyopathies, valvular heart disease, and metabolic conditions, which collectively increase the risk of heart failure.

SUMMARY

A careful assessment of the family history of heart failure and associated risk factors may identify treatable targets that can potentially reduce the likelihood of developing heart failure, and can assist in the implementation of preventive strategies for risk populations with stages A and B heart failure.

Association of clinic and ambulatory blood pressure with vascular damage in the elderly: the EPICARDIAN study

OBJECTIVES

In middle-aged adults, vascular damage correlates better with ambulatory than with clinic blood pressure. This study aimed to determine whether vascular damage evaluated by carotid ultrasonography in the elderly is also more closely related to ambulatory than to clinic blood pressure, and which blood pressure variables are better associated with vascular damage.

METHODS

Cross-sectional study of 292 randomly selected >65 years old participants who underwent 24-h noninvasive ambulatory blood pressure monitoring. Blood pressure variables analyzed were (a) clinic blood pressure: systolic and diastolic blood pressure, pulse pressure; (b) ambulatory blood pressure monitoring: mean values of systolic and diastolic blood pressure, systolic and diastolic blood pressure load, pulse pressure, as well as variability, evaluated within 24 h, diurnal and nocturnal periods; and day-night blood pressure difference. A clinical history, physical examination, carotid ultrasonography and laboratory tests were performed. To estimate the relationship between blood pressure and vascular damage, univariate and multivariate analyses were performed.

RESULTS

Mean age: 73+/-6 years, 45% men, 76.7% hypertensive patients. In the simple regression analysis, the best significant correlations (P<0.05) were common carotid intima-media thickness with 24-h and nocturnal pulse pressure (r=0.32), and common carotid diameter with 24-h systolic blood pressure load (r=0.47). In the multivariate analysis, the significant associations (P<0.05) were (a) linear regression: nocturnal pulse pressure with common carotid intima-media thickness, and diurnal pulse pressure as well as 24-h systolic blood pressure load with common carotid diameter; (b) logistic regression, adjusted odds ratio: nocturnal pulse pressure and nocturnal diastolic blood pressure load with the presence of carotid atherosclerotic plaques 1.03 and 0.98, respectively.

CONCLUSIONS

In the elderly, ambulatory blood pressure monitoring is better associated with carotid damage than clinic blood pressure. Systolic blood pressure variables are the best associated, blood pressure load and pulse pressure being better associated with carotid damage than the mean levels of ambulatory blood pressure.

Differential pulse pressure response to various antihypertensive drug families

Pulse pressure (PP) is emerging as a major pressure predictor of cardiac disease. The study comprised 10 185 untreated patients with essential hypertension. A total of 5395 men and 4790 women 56+/-13 years old, with uncomplicated essential hypertension, after a 15-day washout period and after 6 months of antihypertensive monotherapy were included. All patients included in the final cohort were responders and had normalized their blood pressure. PP was decreased least with diuretics (-5 mm Hg) and most with angiotensin II receptor blockers (ARBs) and calcium antagonists (-15 mm Hg), followed by angiotensin-converting enzyme inhibitors (ACEI) (-12 mm Hg) alpha- and beta-blockers (-10 and -9 mm Hg), differentiating among antihypertensive classes (P<0.001). The magnitude of PP fall was related to the degree of left ventricular (LV) mass reduction (P<0.001), seen best with ARBs (r=0.42) and least with ACEIs (r=0.18). Of the antihypertensive medications used in everyday practice, PP decrease may be achieved best with ARBs and calcium antagonists, whereas diuretics confer poor response. PP was decreased least with diuretics (-5 mm Hg) and most with ARBs and calcium channel blockers (-15 mm Hg), followed by ACEI (-12 mm Hg) alpha- and beta-blockers (-10 and -9 mm Hg), differentiating among antihypertensive classes (P<0.001). Of the antihypertensive medications used in everyday practice, PP decrease may be achieved best with ARBs and calcium antagonists.

The E-selectin gene polymorphism and carotid atherosclerosis in end-stage renal disease

BACKGROUND

E-selectin is a cell surface glycoprotein that mediates the adhesion of leucocytes to vessels endothelium, an important early step in the atherosclerotic process. End-stage renal disease (ESRD) is a highly atherogenic disease but it is unknown whether genetic polymorphism(s) in the E-selectin gene plays a role in the severity of arterial damage in this condition. Method. In this study, we tested whether the Leu554Phe variant in the E-selectin gene is linked to carotid atherosclerosis in 134 well-characterized ESRD patients. The frequency of this polymorphism was also measured in a population sample of the same geographical area.

RESULTS

A total of 84% patients had the CC genotype, 13% had the CT genotype, 3% had the TT genotype and this distribution did not differ from that in the control population. Intima-media thickness (IMT) (P = 0.01) and cross-sectional area (P = 0.02) were significantly higher in patients with the T-allele than in those without this allele. Furthermore, the degree of carotid stenosis was significantly higher (P = 0.02) in patients with T-allele than in CC patients. On multivariate analyses including the traditional and non-traditional risk factors, the Leu554Phe polymorphism was confirmed as an independent correlate of IMT (P = 0.02), cross-sectional area (P = 0.03) and carotid stenosis (P = 0.02).

CONCLUSION

In ESRD, the Leu554Phe polymorphism of E-selectin gene is associated with the severity of carotid atherosclerosis, suggesting that genetically-determined alterations in the E-selectin molecule may render ESRD patients with this gene variant particularly susceptible to the detrimental effects of inflammation on the arterial wall.

Left ventricular hypertrophy in nondiabetic predialysis CKD

BACKGROUND

Although left ventricular hypertrophy (LVH) is a strong predictor of mortality in patients with end-stage renal disease, few studies are available before the start of dialysis treatment. The purpose of this study is to evaluate the prevalence and clinical correlates of LVH in nondiabetic patients with chronic kidney disease (CKD) not yet undergoing renal replacement therapy.

METHODS

We investigated 244 nondiabetic patients with CKD; 57 patients (42 men; age, 20 to 78 years) had stages 1 to 2 CKD and 187 patients (122 men; age, 18 to 77 years) had stages 3 to 5 CKD. Fifty-two normotensive healthy subjects served as controls. Each patient had blood pressure (BP) measured by means of 24-hour ambulatory BP monitoring and left ventricular mass index (LVMi) assessed by means of M-mode echocardiography. Creatinine clearance was estimated by means of the Cockcroft-Gault formula, and hemoglobin, serum lipid, and intact parathyroid hormone concentrations and daily urinary protein excretion were assessed by using routine methods.

RESULTS

In the overall group, prevalences of arterial hypertension and LVH were 66% and 74%, respectively. LVMi was 160 +/- 50 g/m2 body surface area and associated directly with age (P = 0.0013), duration of arterial hypertension (P = 0.0075), 24-hour systolic BP (P = 0.0113), pulse pressure (P = 0.0003), daytime (P = 0.0206) and nighttime systolic BP (P = 0.0059), and urinary protein excretion (P < 0.05) and inversely with creatinine clearance (P = 0.0103) and hemoglobin level (P = 0.0276). In patients with CKD stages 1 to 2 (LVH prevalence, 51%), age, duration of arterial hypertension, pulse pressure, and urinary protein excretion were significant predictors of LVMi (P < 0.00002) by using stepwise regression analysis, whereas in those with CKD stages 3 to 5 (LVH prevalence, 78%), pulse pressure emerged as the sole predictor of LVMi (P = 0.0011).

CONCLUSION

The prevalence of LVH in nondiabetic predialysis patients with CKD is greater than previously reported, and there is evidence that LVH already is present in the early stages of renal disease. Arterial hypertension is associated with LVH in patients with CKD, and the strong relationship between elevated pulse pressure and LVH in those with more advanced CKD suggests that increased arterial stiffness might have a role for LVH well before the start of dialysis therapy.

[Differential pressure as an independent factor of cardiovascular risk]

OBJECTIVES

To confirm that high differential pressure (DP) supposes greater risk of ischaemic cardiopathy and to assess whether it is also an independent risk factor of suffering a cerebrovascular accident.

DESIGN

An analytical, observational, retrospective and longitudinal study with historic cohorts.

SETTING

Urban population of about 18 000 inhabitants.

PARTICIPANTS

300 patients aged between 15 and 75 with hypertension of > or =2 years evolution, who have had their blood pressure taken by nurses 4 or more times (excluding casualty) and have not suffered a cardiovascular event (CVE), whether coronary accident, cerebrovascular accident or peripheral vasculopathy.

MAIN MEASUREMENTS

The history relating to cardiovascular risk was recorded: lipaemia, obesity, tobacco dependency, diabetes mellitus, left ventricular hypertrophy (LVH). These factors were considered present if their diagnosis preceded the CVE diagnosis. They were placed in 2 groups, depending on the degree of differential pressure: "high" if >60 mm Hg and "not high" if (3/4)60 mm Hg. They were analysed for intention to treat over 10 years, with the appearance or not of a CVE as a response variable.

RESULTS

300 participants (73.3% women), 150 exposed to risk and 150 not exposed. The initial analysis showed significant differences between the 2 groups for age (P<.0001), diabetes (P<.0001), and LVH (P<.001). After logistic regression, the OR of suffering LVH was 2.38 (95% CI, 1.19-4.74) in the group with high DP; the OR of ischaemic cardiopathy, 2.84 (95% CI, 1.16-6.96); and of cerebrovascular accident, 2.70 (95% CI, 1.09-6.68). There were no significant differences for peripheral arteriopathy.

CONCLUSIONS

DP was confirmed as an independent factor of cardiovascular risk and, despite the limitations of the study, it was pointed to as a possible independent factor of cerebrovascular risk.

A prognostic role of mean 24-h pulse pressure level for cardiovascular events in type 2 diabetic subjects under 60 years of age

OBJECTIVE

To assess the prognostic role of ambulatory 24-h pulse pressure (PP) on various vascular events in relatively young type 2 diabetic subjects under 60 years of age.

RESEARCH DESIGN AND METHODS

In this prospective study, 237 type 2 diabetic subjects without any history of vascular complications were analyzed. After excluding 9 dropout subjects, 228 subjects (mean age, 46 years; 69% men; mean follow-up period, 100 months) entered the study.

RESULTS

Distribution of 24-h PP for all subjects showed left skewed data, indicating that there may be a diabetic subgroup that had a wide PP. Therefore, further analysis was performed by stratifying the diabetic subjects by quartile of 24-h PP. Outcomes for the widest quartile (n = 58; cut point = 53.3 mmHg) was then compared with those from the other narrower quartiles (n = 170). In the diabetic subjects with a wide PP, cardiovascular events occurred more frequently than those in the diabetic subjects with a narrow one (20.7 vs. 4.1%; P < 0.001), resulting in the significant difference in the cumulative incidence of cardiovascular events (P < 0.001, log-rank test), but not cerebrovascular events, between the two subgroups. The Cox model revealed that a wide 24-h PP at baseline independently predicted subsequent cardiovascular events but not cerebrovascular events. By contrast, only duration of diabetes was the risk factor for cerebrovascular events.

CONCLUSIONS

This study showed that a wide 24-h PP is predictive for cardiovascular events in relatively young diabetic subjects.

Ambulatory Pulse Pressure, Left Ventricular Hypertrophy and Function in Arterial Hypertension

BACKGROUND

A wide pulse pressure (PP) can provide important risk assessment information about myocardial infarction, carotid artery atherosclerosis, and global cardiovascular risk. Ambulatory pulse pressure (APP) does not have a well-known prognostic value in hypertensive patients.

METHODS

To evaluate the relationship among high APP, atrial volumes, and cardiac function, an observational study was performed on 108 untreated non-elderly hypertensive patients (mean age 54.23 +/- 7.12). Twenty-four-hour ambulatory blood pressure monitoring, Doppler and echocardiographic measurements of systolic, diastolic function, left and right atrial volumes, left ventricular mass index and dimensions, were performed in subjects with both clinic and APP > 60 mmHg (APP1 Group). A control group of hypertensive selected subjects with both clinic and APP < 60 mmHg was chosen (APP 2 Group).

RESULTS

The APP1 group showed left atrial volume enlargement, high left ventricular mass index, and impaired diastolic function. A positive correlation was found in the APP1 group results among left ventricular end diastolic diameter (r = 0.39, P < 0.01), left atrial volume (0.38, P < 0.05), and left ventricular mass index (r = 0.33, P < 0.05); clinic PP showed a statistically significant correlation with left atrial volume, left ventricular end diastolic diameter, and left ventricular mass index only in the APP1 group.

CONCLUSIONS

These results suggest that elevated APP can be considered an effective predictor of cardiovascular risk in hypertensive subjects. In these patients echocardiographic evaluation of left ventricular function and morphology can increase the prognostic value of PP.

Blunted Reduction of Pulse Pressure during Nighttime Is Associated with Left Ventricular Hypertrophy in Elderly Hypertensive Patients

Increased pulse pressure (PP) is recognized as a risk factor for cardiovascular disease, especially in elderly patients. However, blood pressure (BP) is known to have a circadian variation. Therefore, this study asked whether or not PP has a circadian variation and, if so, whether a circadian variation of PP has clinical importance. Ambulatory BP monitoring (every 30 min for 48 h) was performed in 255 patients with untreated essential hypertension (24 to 82 years old; mean: 52+/-12 years). Left ventricular mass index (LVMI) was estimated from M-mode echocardiography. PP was decreased during nighttime (10+/-11% reduction from daytime PP). Multivariate linear regression analysis showed that, among four variables-the degree of nighttime PP reduction, daytime PP, 48-h systolic BP, and nondipper hypertension-the degree of nighttime PP reduction had the strongest (inverse) correlation with LVMI in a subgroup of elderly patients (> or =60 years old, n =67) (standardized regression coefficient=-0.32, p =0.02), whereas this association was not significant in the whole patient population unclassified by age. Furthermore, a blunted reduction of nighttime PP in combination with nondipper hypertension was an incremental risk for increase in LVMI in the elderly patients. In conclusion, PP is reduced during nighttime, but the degree of reduction varies among patients. The blunted reduction of nighttime PP is a risk for left ventricular hypertrophy, an established predictor of hypertension-induced cardiovascular events, and it may thus play a role in cardiovascular complications, especially in elderly patients with nondipper hypertension.

Pulse pressure and endothelial dysfunction in never-treated hypertensive patients

OBJECTIVES

This study sought to investigate whether pulse pressure (PP) is associated with endothelium-dependent vasodilation in a group of never-treated hypertensives.

BACKGROUND

Pulse pressure represents a well-established independent predictor for cardiovascular morbidity and mortality. Forearm endothelial dysfunction, defined as impaired vasodilating response to acetylcholine (ACh), may be associated with several cardiovascular risk factors. Recently, the prognostic value of coronary and forearm endothelial dysfunction has been demonstrated.

METHODS

All patients underwent measurement of blood pressure (BP) both clinically and in an ambulatory setting. Endothelium-dependent and -independent vasodilation was investigated by strain-gauge plethysmography in 262 hypertensive patients (age 30 to 55 years) during intra-arterial infusion of increasing doses of ACh and sodium nitroprusside.

RESULTS

We observed that systolic BP rather than diastolic BP significantly induces the PP increase. Linear regression analysis revealed a significant inverse correlation between ACh-stimulated forearm blood flow (FBF) and age, body mass index, clinic and monitored systolic BP, and clinic and monitored PP. However, stepwise multivariate analysis showed that monitored PP was the strongest independent predictor of ACh-stimulated FBF, accounting for 33.6% of the variation. After adjustment for other covariates, ACh-stimulated FBF decreases by 8.7% for each mm Hg increment in monitored PP.

CONCLUSIONS

Our data indicate that monitored PP is inversely correlated with ACh-stimulated vasodilation. It is possible to hypothesize that elevation in PP reduces FBF by increasing oxidative stress and reducing production of nitric oxide caused by reduced shear stress. In addition, the present findings demonstrate the accuracy of ambulatory BP as a prognostic predictor of hypertension-associated endothelial dysfunction.

Pulse pressure responses to psychological tasks improve the prediction of left ventricular mass: 10 years of follow-up

OBJECTIVES

To examine the role of casual blood pressure measurements and blood pressure responses to psychological tasks in the prediction of future left ventricular mass index (LVMI), and to determine the importance of different components of blood pressure, and the predictive value of an individual's personal characteristics and antihypertensive medication on future LVMI.

METHODS

At baseline, blood pressure was recorded by casual measurements; during tests it was recorded by intra-arterial monitoring. The participants were healthy, untreated 35-45-year old men. Echocardiography data both at baseline and after 10 years of follow-up were available from 65 individuals, of whom 49 (75%) were not taking antihypertensive medication at follow-up. Those not taking antihypertensive medication were included in the prediction of LVMI (g/m2).

RESULTS

Baseline LVMI correlated significantly with future LVMI only among the 49 unmedicated individuals (r = 0.52, P < 0.0001). The predictive value of baseline LVMI on future LVMI among them (adjusted coefficient of determination = 0.26) was not improved by the inclusion of casual blood pressure. In contrast, blood pressure responses to the psychological tasks improved the prediction of future LVMI by 4-13%. Pulse pressure was the blood pressure variable that entered the final prediction models; the correlations with future LVMI were best for pulse pressure response to habituation task (r = 0.43, P < 0.05) and to relaxation (r = 0.37, P < 0.05).

CONCLUSIONS

To our knowledge, this is the longest prospective follow-up to show that blood pressure responses to psychological tasks improve the prediction of LVMI compared with casual blood pressure measurements. The pulse pressure, which reflects the properties of the arterial wall, is the most significant blood pressure variable in predicting future LVMI.

Pulsatile and steady 24-h blood pressure components as determinants of left ventricular mass in young and middle-aged essential hypertensives

In order to explore the relations between left ventricular mass (LVM) and the pulsatile (pulse pressure) and steady (mean pressure) components of the blood pressure (BP) curve, 304 young and middle-aged essential hypertensive patients were studied by means of 24-h ambulatory BP monitoring and echocardiography. In the overall study population, both the BP components showed significant correlations with LVM. These correlations were unevenly distributed in the subgroups of subjects younger and in those older than 50 years. While in this latter subgroup, in multivariate analysis, both 24-h mean BP (24-MBP) (beta = 0.27; P = 0.008) and 24-h pulse pressure (24-h PP) (beta = 0.23; P = 0.02) were associated with LVM, in the subset of younger hypertensives only 24-h MBP (beta = 0.21; P = 0.009) was related to LVM, independent of other covariates. The relations observed between 24-h PP and LVM in the entire study population and in the patients older than 50 years lost statistical significance when the effect of 24-h systolic blood pressure (24-h SBP) was taken into account, in a multiple regression model in which 24-h MBP was replaced by 24-h SBP. Our findings seem to suggest that the association of PP with LVM in middle-aged hypertensives may partially explain the increased cardiovascular risk, documented in subjects with high PP. However, this relation is not independent, but is mediated by SBP.

Efficacy and Tolerability of Nilvadipine in Combination with an Angiotensin II Receptor Antagonist in Patients with Essential Hypertension: A Multicenter, Open-Label, Uncontrolled Study

BACKGROUND

Combination therapy with different classes of antihypertensive drugs often is needed to achieve controlled blood pressure (BP). The combination of an angiotensin II receptor antagonist (AIIA) and a calcium antagonist is a preferred option for reducing uncontrolled BP.

OBJECTIVE

The aim of this study was to assess the clinical efficacy and tolerability of nilvadipine, a dihydropyridine calcium antagonist, in combination with an AIIA.

METHODS

Patients with essential hypertension whose BP was not controlled by an AIIA alone were eligible for this multicenter, open-label, uncontrolled study. One of 3 AIIAs (candesartan cilexetil, losartan potassium, or valsartan) was given for at least 10 weeks before the addition of nilvadipine (daily dose, 4 or 8 mg orally). This combination therapy was given for 8 weeks. BP and heart rate were measured between 2 and 4 weeks before and 0, 4, and 8 weeks after the start of combination therapy. Adverse events were monitored at each visit.

RESULTS

Thirty-one patients (18 women [58.1%], 13 men [41.9%]; mean [SD] age, 58.5 [10.5] years) were enrolled. At weeks 4 and 8 of combination therapy, mean systolic BP (SBP) and diastolic BP (DBP) were significantly decreased (P<0.01) (at week 8, by 22.0 mm Hg and 12.5 mm Hg, respectively). The mean BP-lowering effect did not differ significantly between the 3 AIIAs tested. Pulse pressure also decreased significantly at week 8, by 9.6 mm Hg (P<0.01). The responder rate (ie, the percentage of patients with DBP <90 mm Hg or a decrease in DBP ≥10 mm Hg) was 72.0% at week 8. Three patients experienced a total of 4 adverse events: mild or severe flushing, mild headache, and mild palpitation. All of these symptoms resolved after nilvadipine treatment was discontinued.

CONCLUSIONS

Nilvadipine in combination with an AIIA showed good antihypertensive efficacy and was well tolerated in the hypertensive patients in this study. This combination also significantly decreased pulse pressure, suggesting that this combination therapy also may have a beneficial effect in elderly patients with isolated systolic hypertension.

Biochemical endothelial markers and cardiovascular remodeling in refractory arterial hypertension

BACKGROUND

Hypertension is the most important and well established risk factor for atherosclerosis. The vascular and cardiac remodeling present in refractory hypertensive patients are related to endothelial dysfunction, a key factor in early atherogenesis and cardiovascular disease. However the mechanistic relationship among biochemical endothelial function markers, cardiovascular remodeling, and refractory hypertension is unknown.

METHODS

We evaluated the left ventricular mass and function, carotid thickness, and plasma nitrate/nitrite (NO2/NO3), cyclic 3'-5'-guanosine monophosphate (cGMP), and thromboxane B2 (TXB2) levels in refractory hypertensive (RH; n = 20) and healthy (CONTROL; n = 20) subjects 22-65 years old. Carotid thickness, left ventricular mass index (LVMI), and left ventricular fraction ejection (LVFE) were estimated by duplex scan ultrasound. Nitrates/nitrites were assayed using the Griess reaction, and plasma cGMP and thromboxane B2 were determined by enzymatic immunoassay (EIA).

RESULTS

Left ventricular mass index was higher in the RH group (138 +/- 20 vs. 108 +/-17 g/m2, p < 0.001) but there was no significant difference in the ejection fraction (67 +/- 5% vs. 69 +/- 4%). Pulse pressure (61 +/- 9 mmHg vs. 46 +/- 10 mmHg) and carotid thickness (1.59 +/- 0.22m vs. 1.04 +/- 0.14mm) were significantly higher (p < 0.001) in RH patients whereas NO2/NO3, cGMP, and thromboxane B2 plasma concentrations were similar in bot groups.

CONCLUSION

There was no association between cardiovascular remodeling and the particular biochemical markers of endothelial function we assessed in refractory hypertensive patients.

Smooth blood pressure control obtained with extended-release felodipine in elderly patients with hypertension: evaluation by 24-hour ambulatory blood pressure monitoring

OBJECTIVE

To assess, by smoothness index (SI), distribution of the antihypertensive effect of extended-release (ER) felodipine over 24 hours in elderly patients with hypertension.

METHODS

After a 4-week washout phase, 35 elderly patients (mean age 69 +/- 4 years) with mild-to-moderate hypertension received 2 weeks' treatment with ER felodipine 5mg once daily. The dosage of ER felodipine was doubled to 10 mg/day and given for a further 2 weeks in non-responders (sitting clinic blood pressure > 140/90mm Hg). The study had an open-label design with no placebo control. After each period, clinic and ambulatory blood pressures were measured. Trough-to-peak (T/P) ratio was computed by dividing the blood pressure (BP) change at trough (22 to 24 hours after drug intake) by the change at peak (2 adjacent hours with a maximal BP reduction between the second and eighth hour after drug intake). SI was calculated as the ratio between the average of the 24, hourly, treatment-induced BP changes and its standard deviation.

RESULTS

After the initial 2-week treatment period, clinic and 24-hour ambulatory BP values were higher in non-responders (145 +/- 11/87 +/- 8 and 135 +/- 17/80 +/- 6mm Hg, respectively) than in responders (133 +/- 6/81 +/- 3 and 130 +/- 9/77 +/- 7mm Hg). In non-responders, clinic and 24-hour BP values were lowered after a further 2 weeks of treatment with ER felodipine 10 mg/day (128 +/- 11/78 +/- 6 and 128 +/- 12/75 +/- 5mm Hg). SI was high in responders (0.8 +/- 0.8/0.7 +/- 0.7 for systolic/diastolic BP) and low in non-responders (0.5 +/- 0.6/0.3 +/- 0.6) during the first 2-week treatment period. It increased in non-responders after an additional 2 weeks of treatment with ER felodipine 10 mg/day (1.0 +/- 0.8/0.7 +/- 0.6). Median T/P ratios were 0.73 and 0.61 (systolic BP and diastolic BP) in responders and 0.41 and 0.61 in non-responders after 2 weeks of treatment. At variance with SI, T/P ratios did not increase in non-responders after doubling the dosage of ER felodipine (0.34 and 0.18). ER felodipine did not increase 24-hour heart rate. A total of nine adverse events were recorded in six patients (17%), but no patients withdrew from the study.

CONCLUSION

ER felodipine 5 to 10 mg/day smoothly and safely reduces 24-hour ambulatory BP in elderly patients with hypertension.

Cardiovascular remodeling is greater in isolated systolic hypertension than in diastolic hypertension in older adults: the Insufficienza Cardiaca negli Anziani Residenti (ICARE) a Dicomano Study

OBJECTIVE

We investigated cardiac and vascular remodeling in an unselected older population with either diastolic hypertension (HTN) or isolated systolic hypertension (ISH).

BACKGROUND

Isolated systolic hypertension accounts for a substantial proportion of hypertension in individuals older than 65 years and is strongly associated with an increased risk of cardiac and cerebrovascular events. The exact mechanisms underlying the increased risk associated with ISH and elevated pulse pressure (PP), in comparison with HTN, have not been extensively investigated.

METHODS

Community-dwelling residents age >/=65 years in a small town in Italy (Dicomano) were enrolled. Untreated subjects considered in this study included 173 normotensive subjects (blood pressure [BP] <140/90 mm Hg), 95 subjects with HTN (diastolic BP >/=90 mm Hg), and 43 subjects with ISH (BP >/=160/<90 mm Hg). All subjects underwent extensive clinical examination, echocardiography, carotid ultrasonography, and carotid applanation tonometry.

RESULTS

Subjects with ISH had higher left ventricular (LV) mass, which was independently related to PP but not to systolic or mean pressures. Both carotid wall cross-sectional area and vascular stiffness were greater in ISH patients than in HTN and normal subjects and were independently related to PP but not to systolic BP. In addition, ISH was associated with a higher prevalence of carotid plaque and more extensive carotid atherosclerosis.

CONCLUSIONS

In our community-based elderly population, individuals with ISH had higher prevalences of LV hypertrophy and carotid atherosclerosis than subjects with HTN despite lower mean BP. These findings provide potential pathophysiologic mechanisms underlying the associations of ISH and PP with increased risk of cardiovascular morbidity and mortality.

Clinic and ambulatory pulse pressure segregate a cluster of cardiovascular risk factors

Office pulse pressure (PP) has been found to be independently associated with cardiovascular morbidity and mortality. While there is evidence that 24 h blood pressure (BP) is a better marker of the cardiovascular complications of hypertension than office BP, this information is still lacking in regard to PP. The aim of the present study was, therefore, to evaluate possible differences between office and 24 h PP in their relationship with cardiovascular risk profile. This cross-sectional study was performed in a group of 175 (104 M, 71 F) hypertensives (43 never treated before the study) free of clinical evidence of target organ disease. BP was measured at rest and during 24 h monitoring; cardiac structure and function was studied by ultrasounds; biochemical analyses were performed to evaluate some parameters of lipid and carbohydrate metabolism. Patients were divided into tertiles of office PP and of 24 h PP. Those in the highest tertile of PP had a significantly higher office and 24 h systolic BP along with a reduction in peripheral insulin sensitivity. Regarding cardiac structure and function, a significantly higher prevalence of concentric left ventricular hypertrophy (23 vs 55%; P=0.05) and an initial impairment of diastolic function with increase of the A wave was detected in hypertensives with higher PP. No difference between office and 24 h PP in detecting patients at higher cardiovascular risk was observed. In conclusion, office and 24 h pulse pressures were both able to segregate patients with a cluster of cardiovascular risk factors.

Pulse pressure in tests improves the prediction of left ventricular mass: 10 years of follow-up

Literature does not agree with the usefulness of exercise blood pressure (BP) in predicting hypertension or target organ damage. In this prospective 10 years of follow-up, we evaluated if exaggerated BP responses to tests may improve the prediction of left ventricular mass index (LVMI). At baseline, BP was recorded by casual measurements, and during tests using intra-arterial monitoring. The subjects were 97 healthy, untreated 35- to 45-year-old-men (34 normotensive, 29 borderline hypertensive, and 34 mild hypertensive). At 10-year follow-up, echocardiography was performed to 86 (89%) of them. Subjects not taking antihypertensive medication (n = 66) were included in the prediction of LVMI(g m-2). Echocardiography data at baseline was available from 70 (72%) of the subjects, of whom 52 did not use antihypertensive medication at follow-up. Pulse pressure (PP) at supine test (r = 0.337, P = 0.006), PP at dynamic exercise last work load (r = 0.332, P = 0.006), and PP after dynamic exercise (r = 0.316, P = 0.010) were the best BP variables achieved in tests in predicting future LVMI of the 66 subjects. Casual BP did not significantly correlate with future LVMI. The best model in predicting LVMI included PP achieved after dynamic exercise, family history of hypertension, and body mass index (BMI) (adj.R2 = 0.207). Baseline LVMI correlated significantly with future LVMI only among the 52 unmedicated subjects (r = 0.508, P<0.0001). The predictive value of baseline LVMI on future LVMI among them (adj.R2 = 0.243) was best improved by PP achieved in supine test and age (adj.R2 = 0.350). In conclusion, BP measurements during tests improved the prediction of LVMI compared with casual BP. For the first time, the pulsatile component of BP in tests was found to be the most significant BP parameter in predicting future LVMI.

Isolated systolic hypertension is associated with adverse outcomes from coronary artery bypass grafting surgery

Isolated systolic blood pressure has not been sufficiently studied in the perioperative setting and may contribute to morbidity and mortality after coronary artery bypass grafting (CABG) surgery. Our objective was to determine the prevalence of isolated systolic hypertension among patients who had CABG surgery and to assess whether isolated systolic hypertension is associated with perioperative and postoperative in-hospital morbidity or mortality. Patients who underwent CABG were selected from a prospective epidemiological study involving 2417 patients in 24 medical centers. Patients were classified as having normal preoperative blood pressure, isolated systolic hypertension (systolic blood pressure >140 mm Hg), diastolic hypertension (diastolic blood pressure >90 mm Hg), or a combination of these. Demographic risk factors (age, sex, and ethnicity), clinical risk factors (diabetes mellitus, increased cholesterol, antihypertensive medications, history of congestive heart failure, myocardial infarction, hypertension, and neurological deficits), and behavioral risk factors (smoking and heavy drinking) were controlled for statistically. Adverse outcomes included left ventricular dysfunction, cerebral vascular dysfunction or events, renal insufficiency or failure, and all-cause mortality. Isolated systolic hypertension was found in 29.6% of patients. Unadjusted isolated systolic hypertension was associated with a 40% increased risk of adverse outcomes (odds ratio, 1.4; confidence interval, 1.1-1.7). After adjusting for other potential risk factors, the increased risk of adverse outcomes with isolated systolic hypertension was 30%. We conclude that isolated systolic hypertension is associated with a 40% increase in the likelihood of cardiovascular morbidity perioperatively in CABG patients. This increase remains present regardless of antihypertensive medications, anesthetic techniques, and other perioperative cardiovascular risk factors (e.g., age older than 60 yr or history of congestive heart failure, myocardial infarction, or diabetes).

IMPLICATIONS

Isolated systolic hypertension is associated with a 40% increase in the likelihood of perioperative cardiovascular morbidity in coronary artery surgery patients.

Relations of pulse pressure and other components of blood pressure to preclinical echocardiographic abnormalities

OBJECTIVE

To evaluate the extent to which pulse pressure (PP) is associated with echocardiographic abnormalities, and in particular to whether PP is related to LV hypertrophy taking into account other blood pressure (BP) components.

DESIGN

Cross-sectional.

SETTING

University hospital, hypertension outpatient unit.

PARTICIPANTS

A total of 275 adults (mean age 47 years, range 19-69, 3% aged > or = 65) with essential hypertension. Overt coronary artery disease, valvular disease and secondary hypertension were exclusion criteria. Subjects were divided in two groups with PP < or = 50 or PP > 50 mmHg.

OUTCOME MEASURES

Left ventricular (LV) mass, hypertrophy, LV systolic dysfunction.

RESULTS

Prevalence of LV hypertrophy was higher in subjects with clinic PP > 50 mmHg. Subjects with PP > 50 mmHg had higher clinic and ambulatory systolic than subjects with PP < or = 50 mmHg while diastolic BP did not differ between groups. PP and systolic BP, either clinic or ambulatory, showed similar correlation to LV hypertrophy in separate logistic multivariate models. Using different methodologies, PP was not related to LV mass index or hypertrophy when the effect of its component systolic BP was taken into account. In separate analyses, PP was not significantly related to ejection fraction or midwall mechanics.

CONCLUSION

Middle-aged clinically healthy hypertensives with PP > 50 mmHg had two-fold higher prevalence of LV hypertrophy than those with PP < or = 50 mmHg, which may contribute to the higher cardiovascular risk in subjects with higher PP. However, in our sample, PP was not related to LV hypertrophy independently of systolic BP, suggesting that systolic BP is the explanatory link of the relation between PP and LV hypertrophy.

Twenty-four hour ambulatory blood pressure in the International Nifedipine GITS Study Intervention as a Goal in Hypertension Treatment (INSIGHT)

OBJECTIVES

The International Nifedipine GITS Study Intervention as a Goal in Hypertension Treatment (INSIGHT) showed, by means of office blood pressure measurements, that long-term treatment with nifedipine GITS is as effective as diuretics in preventing cardiovascular and cerebrovascular complications. However, since office blood pressure measurements reflect to a limited extent blood pressure outside the office, a side-arm INSIGHT study in which patients underwent both office measurement and 24 h ambulatory blood pressure monitoring was also performed.

DESIGN AND METHODS

The study had a randomized, double-blind, parallel group design. After 4 weeks of placebo, mild-to-moderate essential hypertensive patients were randomized to nifedipine GITS 30 mg or amiloride 2.5 + hydrochlorothiazide 5 mg for 3.1 years. Dose titration was performed by dose doubling and addition of atenolol 25-50 mg or enalapril 5-10 mg, or other drugs when needed. Analysis was carried out by intention-to-treat and included computation of 24 h, day and night ambulatory blood pressure and heart rate values. Additional analyses included computation of the trough-to-peak ratio and the smoothness index (the ratio between the average of the 24-hourly blood pressure reductions after treatment and its standard deviation).

RESULTS

A total of 151 patients were recruited and 149 were valid for analysis: 78 patients had 24 h ambulatory recordings both at baseline and during treatment and 134 during treatment. Office, 24 h and day and night blood pressures were all significantly and similarly reduced by both treatments. Office and ambulatory heart rate was left unchanged by diuretics, while it was slightly reduced by nifedipine. Median trough-to-peak ratios were always > 0.5 and superimposable between the two treatment groups. Similarly, smoothness indices of systolic and diastolic blood pressures were comparably high for nifedipine and diuretics, thus demonstrating a similar well-balanced antihypertensive response to both drugs. No significant differences were observed between the two treatment groups in the number of cardiovascular events (17 in the nifedipine-based and 26 in the diuretics-based treatment group).

CONCLUSIONS

In the INSIGHT study, the long-term antihypertensive effect on 24 h blood pressure and the cardiovascular protection of nifedipine was similar to that of diuretics.

Correlates of pulse pressure reduction during antihypertensive treatment (losartan or atenolol) in hypertensive patients with electrocardiographic left ventricular hypertrophy (the LIFE study)

In hypertensive patients, pulse pressure has been related to hypertension-induced target organ damage and risk of cardiovascular events. However, correlates of pulse pressure reduction during antihypertensive treatment have been less extensively investigated. We related pulse pressure changes to clinical and echocardiographic findings before and after 2 years of antihypertensive treatment in 767 patients aged 55 to 80 years (mean 66) in the Losartan Intervention For End point reduction in hypertension study. Over 2 years, blood pressure and pulse pressure were reduced from 173/98 to 147/84 mm Hg and from 75 to 63 mm Hg, respectively, both p <0.001. In linear multivariate analysis controlling for initial pulse pressure, 2-year reduction in pulse pressure correlated negatively with age and concomitant diabetes mellitus, and positively with body height and 2-year reduction in mean blood pressure (multiple R(2) = 0.42, p <0.01). When dividing the study population into 2 groups using a prognostically validated partition for pulse pressure, patients with pulse pressure > or =63 mm Hg after 2 years of antihypertensive treatment (n = 349) were older and shorter, included more women and patients with isolated systolic hypertension, diabetes mellitus, albuminuria, and echocardiographic left ventricular hypertrophy at baseline, and also had a smaller decrease in mean blood pressure and the urinary albumin/creatinine ratio over 2 years (all p <0.05). Thus, in hypertensive patients with electrocardiographic left ventricular hypertrophy, older age, less reduction in mean blood pressure, concomitant diabetes mellitus, and shorter stature are associated with attenuated pulse pressure reduction during antihypertensive treatment.

Assessment of outcomes other than systolic and diastolic blood pressure: pulse pressure, arterial stiffness and heart rate

In recent years, studies have shown that parameters derived from the arterial pressure wave other than systolic and diastolic blood pressure provide important information on cardiovascular status. Among these parameters, pulse pressure, arterial stiffness and heart rate have emerged as independent markers of cardiovascular risk in different populations. Although a number of studies have used casual measurements of these parameters in a clinic setting, others have focused on their assessment under ambulatory conditions. The pulse pressure represents the amplitude of the pressure wave signal (systolic minus diastolic blood pressure), higher pulse pressure values having been reported in patients possessing cardiovascular risk factors. Close associations between a high pulse pressure and several surrogate end-points have been described. Furthermore, epidemiological studies have shown that a high pulse pressure is an independent predictor of hard end-points in several populations. Arterial stiffness represents one of the major haemodynamic factors determining pulse pressure. Pulse wave velocity, measured from the initial upstroke of the pressure wave, constitutes an established index of arterial stiffness. Studies have reported stiffer arteries in patients with cardiovascular pathology even at an early stage of disease. Close correlations between arterial stiffness and several surrogate markers have been reported, and arterial stiffness and its changes have recently been shown to be an independent predictor of hard end-points in patients with a high cardiovascular risk. Methods to evaluate arterial stiffness under ambulatory conditions are emerging. Heart rate represents the frequency of the cyclical strain of the arterial wall, clinical studies having shown that ambulatory heart rate is correlated to several surrogate markers. A few epidemiological studies have analysed the value of ambulatory heart rate as an independent predictor of hard end-points, but their positive findings need to be confirmed. The analysis of the pressure wave thus allows the determination of several haemodynamic indices other than systolic and diastolic blood pressure. Pulse pressure, arterial stiffness and heart rate constitute other outcomes that may be useful as additional factors in risk assessment for future therapeutic decision-making.

Cardiac and vascular remodeling in older adults with borderline isolated systolic hypertension: the ICARe Dicomano Study

Although borderline isolated systolic hypertension (ISH), defined as a blood pressure of 140 to 159/<90 mm Hg, is a proven cardiovascular risk factor, the major clinical trials on treatment of ISH have used a cutoff of 160 mm Hg. Moreover, no data exist on the cardiovascular modifications associated with borderline ISH. Therefore, we compared subjects with borderline ISH to subjects with diastolic hypertension (diastolic blood pressure > or =90 mm Hg) or ISH. Community-dwelling residents (age > or =65 years) of a small town in Italy (Dicomano) underwent extensive clinical examination, echocardiography, carotid ultrasonography, and applanation tonometry. Only untreated subjects were included in this analysis: 95 with diastolic hypertension, 87 with borderline ISH, and 43 with ISH. Despite lower systolic and mean pressures in borderline ISH, left ventricular mass was similar to that in diastolic hypertension. In univariate and multivariate analysis, pulse pressure but not systolic pressure was related to left ventricular mass. Borderline ISH subjects had a tendency to greater carotid cross-sectional area and stiffness index than did diastolic hypertensive subjects despite lower mean carotid pressure, whereas the number of atherosclerotic plaques was similar in the 2 groups. Pulse pressure but not systolic pressure was independently related to carotid remodeling. In our community-based, older population, individuals with borderline ISH had a similar prevalence of left ventricular hypertrophy and carotid atherosclerosis as that of subjects with diastolic hypertension, despite lower systolic and mean pressures. Among blood pressure values, pulse pressure was the single or strongest independent predictor of cardiovascular remodeling.

Blood pressure variability as a risk factor

Blood pressure variability is clinically relevant because of the evidence that the degree of blood pressure fluctuation may independently contribute to organ damage and to the cardiovascular risk of hypertensive patients. This review will focus on the evidence available to support this concept. As such, data obtained from cross-sectional studies, longitudinal studies in humans and experimental studies in animals will be discussed. The possibility of antagonizing an excessive degree of blood pressure variability by administering drugs to provide a long-lasting and smooth antihypertensive action will also be discussed, as will the usefulness of mathematical indices aimed at quantifying the homogeneity of the blood pressure reduction by treatment.