Cardiac and vascular structural changes. Prevalence and relation to ambulatory blood pressure in a middle-aged general population in northern Italy: the Vobarno Study

Retinal microvascular alterations in patients with active rheumatoid arthritis without cardiovascular risk factors: the potential effects of T cell co-stimulation blockade

Background

The evaluation of microvascular alterations might provide clinically useful information for patients with an increased cardiovascular (CV) risk, such as those with rheumatoid arthritis (RA), being the small artery remodeling the earliest form of target organ damage in primary CV diseases, such as arterial hypertension. The evaluation of retinal arterioles is a non-invasive technique aimed to identify an early microvascular damage, represented by the increase of the wall-to-lumen ratio (WLR) index. Abatacept (ABA), a T-cell co-stimulator blocker, is used to treat RA. A CV protective action was hypothesized for its peculiar mechanism of action in the modulation of T-cells, potentially involved in the pathogenesis of CV comorbidity. The study aimed to non-invasively investigate morphological characteristics of retinal arterioles in a cohort of RA patients treated with ABA.

Materials and methods

Seventeen RA patients [median (25th-75thpercentile) age = 58 (48-64) years, baseline 28-joint Disease Activity Score DAS28-C-reactive protein (DAS28-CRP) = 4.4 (3.9-4.6), body mass index (BMI) = 24.2 (23.4-26) kg/m2, rheumatoid factor positive:52.9%, anti-citrullinated peptide autoantibodies positive:76.5%] without known CV risk factors (arterial hypertension, diabetes, hypercholesterolemia, previous CV events, smoking) were evaluated by the adaptive optics imaging system of retinal arterioles before and every 6 months of therapy with ABA (T0, T6 and T12). Office blood pressure evaluation, 24-h ambulatory blood pressure monitoring and tissue-doppler echocardiography were also performed.

Results

A progressive significant reduction of the WLR of retinal arterioles was observed [T0 = 0.28 (0.25-0.30), T6 = 0.27 (0.24-0.31), T12 = 0.23 (0.23-0.26); p T0 vs. T6 = 0.414; p T6 vs. T12 = 0.02; p T0 vs. T12 = 0.009], without significant variations in other parameters. The T0-T12 reduction of WLR was correlated with that of DAS28-CRP (r:0.789; p = 0.005). Moreover, a significant reduction of diastolic office blood pressure and a trend for reduction of daily pressure measured by ambulatory monitoring were observed.

Conclusion

In a cohort of RA patients without known CV risk factors, a reduction of retinal microvascular alterations was demonstrated after treatment for 12 months with ABA, in parallel with the reduction of disease activity. These results might suggest the possibility of microvascular abnormalities regression induced by the immune system modulation.

Association of blood pressure measurements in sitting, supine, and standing positions with the 10-year risk of mortality in Korean adults

OBJECTIVES

This prospective cohort study investigated the association between blood pressure (BP) as measured in different body postures and all-cause and cardiovascular (CV) mortality risk.

METHODS

This population-based investigation included 8,901 Korean adults in 2001 and 2002. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured sequentially in the sitting, supine, and standing positions and classified into 4 categories: 1) normal, SBP <120 mmHg and DBP <80 mmHg; 2) high normal/prehypertension, SBP 120-129 mmHg and DBP <80 mmHg/SBP 130-139 mmHg or DBP 80-89 mmHg; 3) grade 1 hypertension (HTN), with SBP 140-159 mmHg or DBP 90-99 mmHg; and 4) grade 2 HTN, SBP ≥160 mmHg or DBP ≥100 mmHg. The date and cause of individual deaths were confirmed in the death record data compiled until 2013. Data were analyzed using Cox proportional hazard regression.

RESULTS

Significant associations were found between the BP categories and all-cause mortality, but only when BPs were measured in the supine position. The multivariate hazard ratios (95% confidence intervals) were 1.36 (1.06-1.75) and 1.59 (1.06-2.39) for grade 1 and grade 2 HTN, respectively, compared with the normal category. The associations between the BP categories and CV mortality were significant regardless of body posture among participants ≥65 years, whereas they were significant for supine BP measurements only in those <65 years.

CONCLUSIONS

BP measured in the supine position predicted all-cause mortality and CV mortality better than BP measured in other postures.

From Structural to Functional Hypertension Mediated Target Organ Damage—A Long Way to Heart Failure with Preserved Ejection Fraction

Arterial hypertension (AH) is a major risk factor for the development of heart failure (HF) which represents one of the leading causes of mortality and morbidity worldwide. The chronic hemodynamic overload induced by AH is responsible for different types of functional and morphological adaptation of the cardiovascular system, defined as hypertensive mediated target organ damage (HMOD), whose identification is of fundamental importance for diagnostic and prognostic purposes. Among HMODs, left ventricular hypertrophy (LVH), coronary microvascular dysfunction (CMVD), and subclinical systolic dysfunction have been shown to play a role in the pathogenesis of HF and represent promising therapeutic targets. Furthermore, LVH represents a strong predictor of cardiovascular events in hypertensive patients, influencing per se the development of CMVD and systolic dysfunction. Clinical evidence suggests considering LVH as a diagnostic marker for HF with preserved ejection fraction (HFpEF). Several studies have also shown that microalbuminuria, a parameter of abnormal renal function, is implicated in the development of HFpEF and in predicting the prognosis of patients with HF. The present review highlights recent evidence on the main HMOD, focusing in particular on LVH, CMD, subclinical systolic dysfunction, and microalbuminuria leading to HFpEF.

Disparate Associations of 24-h Central Aortic and Brachial Cuff Blood Pressure With Hypertension-Mediated Organ Damage and Cardiovascular Risk

Objective

Aim of this study was to evaluate the associations of non-invasive central aortic and peripheral (brachial) blood pressure (BP) for Hypertension-mediated organ damage (HMOD) and atherosclerotic cardiovascular disease (ASCVD) risk.

Methods

We evaluated associations of HMOD with 24-h ambulatory blood pressure monitoring (ABPM) of central aortic and peripheral BP indices in patients with primary hypertension and presence of several cardiovascular risk factors. BP measurements were performed by means of a non-invasive automated oscillometric device (Mobil-O-Graph). HMOD was defined as the presence of carotid intima-media thickness (IMT) above normal values and/or carotid plaque, left ventricular hypertrophy (LVH), and/or renal abnormalities as assessed by urine albumin/creatinine ratio above normal values and/or estimated glomerular filtration rate (eGFR) <60 ml/min per 1.73 m².

Results

In the study cohort of 273 (age 55.2 ± 13.4 years, 71.8% male) patients with primary hypertension, documented HMOD was present in 180 (65.9%), LVH in 70 (25.6%), increased IMT in 129 (47.3%). Fifty-six patients (20.5%) had kidney organ damage (20.5% albuminuria and 2.6% impaired eGFR). When accounting for confounding factors (age, sex, body-mass-index, antihypertensive treatment, smoking, triacylglycerol, statin treatment, glucose, hypoglycemic therapy, or heart rate) only peripheral 24-h pulse pressure (PP) maintained statistical significance with HMOD indices (OR: 1.126, 95% CI: 1.012~1.253; p = 0.029). Using ASCVD risk score as the independent continuous variable in multiple linear regression, 24-h central systolic pressure (SBP) (β = 0.179; 95% CI:0.019~0.387; p = 0.031), daytime central PP (β = 0.114; 95% CI:0.070~0.375; p = 0.005, night-time central SBP (β = 0.411; 95% CI:0.112~0.691; p = 0.007) and night-time PP (β = 0.257; 95% CI:0.165~0.780; p = 0.003) were all positively associated with ASCVD risk.

Conclusions

Blood pressure obtained by 24-h ABPM was better correlated with HMOD than office BP. Whilst 24-h peripheral BP showed a stronger association with HMOD than 24-h central BP, the prognostic value of 24-h central BP for the 10-year ASCVD risk was superior to 24-h peripheral BP.

Prevalence of hypertension mediated organ damage in subjects with high-normal blood pressure without known hypertension as well as cardiovascular and kidney disease

Purpose of our study was to assess the prevalence of hypertension mediated organ damage (HMOD) in healthy subjects with high-normal Blood Pressure (BP) comparing them with subjects with BP values that are considered normal (<130/85 mmHg) or indicative of hypertension (≥140/90 mmHg). Seven hundred fifty-five otherwise healthy subjects were included. HMOD was evaluated as pulse wave velocity (PWV), left ventricular mass index (LVMI), and carotid intima-media thickness (IMT) and plaque. When subjects were classified according to BP levels we found that the high-normal BP group showed intermediate values of PWV and higher values of IMT. This corresponds to intermediate prevalence of arterial stiffness, while there were no differences for increased IMT or carotid plaque. No subjects showed left ventricular hypertrophy. At multivariable analysis, the odds of having arterial stiffness or carotid HMOD in the high-normal group resulted not different to the normal group. In conclusion, in our otherwise healthy population, high-normal BP values were not related to aortic, carotid or cardiac HMOD.

The Vobarno study

INTRODUCTION

The Vobarno study represents the first observational study aimed to assess in a general population sample the relationship between parameters of cardiac and vascular structure (and function) and blood pressure values, measured in the clinic and during the 24 hours.

EVIDENCE ACQUISITION AND SYNTHESIS

In the frame of the Vobarno study blood samples for hematochemistry and DNA extraction, clinic and 24-hour blood pressure measurements, cardiac and carotid ultrasound, and aortic stiffness were measured in all subjects, living in a small town (Vobarno) between Brescia and the Garda lake, and randomly selected from electoral roles. In this sample of a general population an extensive evaluation of organ damage, including left ventricular (LV) mass and hypertrophy, LV systolic function, left atrial dimensions and aortic root diameters, carotid intima media thickness (IMT) and carotid plaques, carotid and aortic stiffness were performed. In this study subjects were included in a long follow-up, lasting 25 years, and cardiovascular morbility and mortality were assessed up to 2019. This will allow to update the information related to cardiovascular morbidity and mortality in the study cohort.

CONCLUSIONS

The present paper will report the results of some analyses performed, exploring epidemiological and clinical aspects of target organ damage.

Cardiovascular target organ damage in premenopausal systemic lupus erythematosus patients and in controls: Are there any differences?

OBJECTIVE

to analyze the presence of cardiac and vascular preclinical damage in premenopausal women with systemic lupus erythematosus (SLE) and controls, matched for demographic characteristics and for other cardiovascular risk factors.

METHODS

33 women (mean age 32 ± 7 years) with SLE clinically stable (SLEDAI Score 2.5 ± +1.5) and 33 controls, matched (MC) for sex, age, body mass index (BMI), clinic blood pressure (BP) and antihypertensive treatment (if present) underwent: 24-h BP monitoring, echocardiography with tissue Doppler analysis for left ventricular (LV) structure, systolic and diastolic function, echo-tracking carotid ultrasound for intima-media thickness (IMT) and carotid distensibility measurement, and pulse wave velocity measurement for aortic stiffness (PWV).

RESULTS

by definition no difference was observed for age, sex, BMI and clinic BP values; Framingham risk score was low in SLE and MC (1.3 ± 2.7 vs 1.5 ± 2.3%, p = ns). 24-h BP was similar in SLE and in MC. Systolic function parameters, including LV longitudinal systolic function, an early index of LV systolic dysfunction, were reduced in SLE as compared to MC. Carotid IMT and carotid and aortic stiffness parameters were not different in SLE and MC. At multivariate regression analysis, PWV was independently associated with LV mass in controls and with the steroid weekly dose in SLE patients.

CONCLUSIONS

in young patients with SLE and low activity index of the disease, we did not observe significant vascular alterations as compared to controls with similar CV risk. The early LV systolic impairment observed in SLE patients needs confirmation.

[Prevalence and determinants of the increased carotid intima-media thickness in a population of 1203 black African hypertensive]

OBJECTIVES

To evaluate the prevalence and determinants of increased carotid intima-media thickness (IMT) in a population of black hypertensive patients and it influence of on the assessment of their overall cardiovascular risk.

PATIENTS AND METHODS

This was a 16-month, cross-sectional study conducted in the outpatient unit of the cardiology department of the Campus teaching hospital of Lome, and included 1203 hypertensive patients, both sexes, aged 35 years and more. Each patient benefited from a carotid IMT measure. Carotid IMT was increased if it was>0.9mm and the plaque was defined as a carotid IMT>1.2mm.

RESULTS

The mean age of our patients was 53.3±10.4 years with a sex ratio of 1.6 in favor of women. The duration of hypertension was less than 5 years in 56.7% and hypertension was grade 1 in 47.7% of cases. The mean carotid IMT was 0.89mm±0.20. The prevalence of the increased carotid IMT was 45.8% and that of an atheroma plaque was 15.8%. Carotid IMT was correlated with age (P˂0.0001), duration of arterial hypertension (P=0.01), history of stroke (P˂0.0001), and presence of left ventricular hypertrophy to cardiac ultrasound (P=0.01). The overall cardiovascular risk was modified after taking into account the carotid IMT. An increase in cardiovascular risk was observed in 30.5% of hypertensive patients.

CONCLUSION

Increased carotid intima-media thickness is frequent in Togolese hypertension. The determining factors are age, duration of arterial hypertension, left ventricular hypertrophy and stroke. The systematic measurement of the carotid intima-media thickness would better evaluate the overall cardiovascular risk for our patients.

Review: The role of noninvasive hemodynamic monitoring in the evaluation and treatment of hypertension

Advances in the understanding of the mechanisms accounting for the elevation of arterial pressure in essential hypertension suggest that there is value in assessing the relative contribution of hemodynamic factors in tailoring specific therapies to control arterial pressure. The non-invasive method of impedance cardiography (ICG) to measure hemodynamic abnormalities in hypertensive patients has emerged as a valuable adjuvant in the decision-making process of selecting antihypertensive agents. The technique is both accurate and reproducible in delineating the hemodynamic mechanisms of hypertension, comparing age-and gender-related changes in hemodynamics, detecting the presence of left ventricular dysfunction, and demonstrating clinically significant improvement in blood pressure control using ICG-guided therapy.

Vascular alterations in apolipoprotein A-I amyloidosis (Leu75Pro). A case-control study

BACKGROUND

Among hereditary amyloidoses, apolipoprotein A-I (APO A-I) amyloidosis (Leu75Pro) is a rare, autosomal dominant condition in which renal, hepatic, and testicular involvement has been demonstrated.

OBJECTIVE

To investigate vascular structural as well as functional alterations.

METHODS

In 131 carriers of the amyloidogenic Leu75Pro APO A-I mutation (mean age 52 + 16 years, 56 women) and in 131 subjects matched for age, sex, body mass index and clinic blood pressure (BP), arterial stiffness (pulse wave velocity, PWV) and carotid intima-media thickness (IMT) were measured.

RESULTS

By definition no differences for age, sex, body mass index, and BP were observed. Meanmax IMT (Mmax-IMT) in the common (CC), bifurcation (BIF) and internal (ICA) carotid artery were comparable in the two groups. After adjustment for high-density lipoprotein cholesterol and renal function differences between the two groups, a lower meanmax-IMT was observed in APO A-I Leu75Pro mutation carriers than in controls (CC Mmax-IMT 0.87 ± 0.21 versus 0.93 ± 0.2 mm, p = 0.07; BIF Mmax-IMT 1.19 ± 0.48 versus 1.36 ± 0.46 mm, p = 0.025; ICA Mmax-IMT 0.9 ± 0.37 versus 1.02 ± 0.35 mm, p = 0.028). On the other hand, aortic stiffness was significantly greater in patients with APO A-I amyloidosis than controls (PWV 11.5 ± 2.9 and 10.7 ± 2.3 m/s, p < 0.05), even after adjusting for confounders.

CONCLUSIONS

In carriers of the amyloidogenic Leu75Pro APO A-I mutation, a significant increase in arterial stiffness is observed; on the contrary, carotid artery IMT is comparable to that of control subjects. These results may add significant information to the clinical features of this rare genetic disorder.

Task force on: 'Early markers of atherosclerosis: influence of age and sex'

Atherosclerosis and its complications are the most important causes of death all over the world, especially in Western countries. Diet habits, modern stress life, smoking, sedentary way of life and an involvement of genetic pattern of individuals lead to a sure degeneration of quality of life increasing the risk of atherosclerosis development. For this reason, the main purpose of actual medicine is to identify all the markers that could allow the physicians to evaluate the first moments of the development of this dangerous pathological process. The aim is to reduce the speed of its evolution, trying to delay indefinitely the risk coming from the morphological alterations of the vessels. 'Endothelium function' could allow physicians to detect the first moment of the natural history of atherosclerosis process. Its impairment is the first step in the degeneration of vascular structures. Many methods [flow-mediated vasodilatation (FMD); antero-posterior abdominal aorta diameter (APAO); intima-media thickness of the common carotid artery (CCA-IMT); arterial stiffness; and so on] try to evaluate its function, but many limitations come from general population characteristics. A standardization of the methods should take into account individuals' peculiarities. Two elements, not modifiable, should be taken into account for vascular evaluation: age and sex. The aim of this review is to outline the linkage among age, sex and instrumental evaluation of patients considered for a noninvasive assessment of their cardiovascular risk profile.

Resistant hypertension and target organ damage

Cardiovascular (CV) complications such as myocardial infarction, heart failure, stroke and renal failure are related to both the degree and the duration of blood pressure (BP) increase. Resistant hypertension (RH) is associated with a higher risk of CV complications and a higher prevalence of target organ damage (TOD). The relationship between CV disease and TOD can be bidirectional. Elevated BP in RH may cause CV structural and functional alterations, and the development or persistence of left ventricular hypertrophy, aortic stiffness, atherosclerotic plaques, microvascular disease and renal dysfunction, may render hypertension more difficult to control. Specifically, RH is related to several conditions, including obesity, sleep apnea, diabetes, metabolic syndrome and hyperaldosteronism, characterized by an overexpression of humoral and hormonal factors that are involved in the development and maintenance of TOD. Optimal therapeutic strategies, including pharmacological treatment and innovative invasive methodologies, have been shown to achieve adequate BP control and induce the regression of TOD, thereby potentially improving patient prognosis.

Endothelial function affects early carotid atherosclerosis progression in hypertensive postmenopausal women

OBJECTIVES

Endothelial dysfunction is known to be associated with atherosclerosis progression and cardiovascular events. Limited information exists regarding the importance of this topic in hypertensive postmenopausal women. In this particular population the influence of endothelial dysfunction on cardio-vascular end cerebro-vascular events is well demonstrated. Therefore, we investigated, in a prospective study, the influence of endothelial-dependent vasodilation on carotid intima-media thickness (IMT) progression in our population of hypertensive postmenopausal women.

METHODS

In addition to common risk factors and pharmacological therapy, we measured carotid IMT and flow-mediated dilation (FMD) of the brachial artery at baseline and after 1 year of follow-up.

RESULTS

Baseline and follow-up data were available for 618 hypertensive postmenopausal women with an age of 55 ± 8 years. The mean IMT at baseline was 754 ± 161 μm [interquartile range (IQR) from 600 to 838 μm]. The mean FMD at baseline was 5.8 ± 3.9% (IQR from 3.2 to 8.2%). There was a significant correlation between baseline FMD and carotid IMT (r = -0.16; P = 0.003). Mean IMT progression resulted in 103 μm (range from -250 to 567 μm; IQR from 0 to 200 μm) per year. Baseline FMD, FMD change and the amount of SBP reduction during follow-up remained the independent predictors of IMT progression in multivariable analysis.

CONCLUSIONS

In this prospective study we observed a significant interaction between baseline FMD, FMD change during follow-up and IMT progression in our population of hypertensive postmenopausal women. These results are in accordance with the suggestion that endothelial dysfunction is associated with enhanced atherosclerosis development. This hypothesis could provide a pathophysiological explanation for the increase in cardio-vascular and cerebro-vascular episodes recorded in hypertensive postmenopausal women with endothelial dysfunction.

Correlations between left ventricular mass index and cerebrovascular lesion

Left ventricular (LV) mass and LV geometry are well-established measures of hypertension chronicity and severity, have a prognostic value on cardiovascular morbidity and mortality, and are related to asymptomatic cerebral small-artery disease (SAD) and largeartery disease (LAD). The aim of the present study was to clarify the different effects of LV mass and LV geometry on underlying SAD compared with its effects on underlying LAD in ischemic stroke patients. Four hundred three ischemic stroke patients underwent echocardiography to determine LV mass index and relative wall thickness. Brain magnetic resonance imaging, angiography, and carotid magnetic resonance angiography were preformed to detect LAD (≥50% stenosis) and SAD (leukoaraiosis, microbleeds, and old lacunar infarction) in the brain. Multivariate analyses showed that the LV mass index was highly associated with underlying SAD but not with underlying LAD. Among the various subtypes of SAD, only cerebral microbleeds were closely related to the LV mass index. Concentric LV hypertrophy was not related to the presence of either SAD or LAD. Subgroup analyses revealed that, among the various subtypes of SAD, only cerebral microbleeds were associated with concentric LV hypertrophy. In conclusion, cerebral microbleeds may imply more advanced target organ damage than underlying LAD and ischemic subtypes of SAD.

Headache: Prevalence and relationship with office or ambulatory blood pressure in a general population sample (the Vobarno Study)

The association of headache and arterial hypertension is still controversial, although headache is usually considered a symptom of hypertension. The aim of this study is to evaluate the prevalence of headache in a general population sample and the relationship with arterial hypertension, as diagnosed by office measurements and ambulatory monitoring of blood pressure (BP).

PATIENTS AND METHODS

In the randomized sample of the Vobarno population, 301 subjects (126 males, 175 females, age range 35-50 years) underwent a structured standardized headache questionnaire, office and 24-h ambulatory BP monitoring.

RESULTS

Prevalence of lifetime headache and of migraine was greater in females than in males. Office and 24-h BP values did not differ between subjects without headache and subjects with headache. No differences in headache prevalence (58% vs 55%), migraine prevalence (32% vs 28%) and use of analgesic drugs in the presence of headache (82% vs 78%) were observed between hypertensive patients (93.5% newly diagnosed, 6.5% treated) and normotensive subjects.

CONCLUSIONS

In a general population sample, hypertension (diagnosed by office and/or 24-h BP) is not associated with headache.

Ambulatory blood pressure, blood pressure variability and the prevalence of carotid artery alteration: the Ohasama study

OBJECTIVES

To investigate the association between ambulatory blood pressure (BP) variables (level, short-term variability, circadian variation and morning pressor surge) and carotid artery alteration in a general population.

METHODS

We measured ambulatory BP every 30 min in 775 participants (mean age 66.2 +/- 6.2 years, 68.8% women) from the Japanese general population. Short-term BP variability during the daytime and night-time were estimated as within-subject standard deviation of daytime and night-time BP, respectively. Circadian BP variation was calculated as the percentage decline in nocturnal BP. Morning pressor surge was defined as morning BP minus pre-waking BP. The extent of carotid artery alteration was evaluated as the average of common carotid intima-media thickness (IMT) and the presence of focal carotid plaque.

RESULTS

Daytime and night-time BP values were more closely associated with carotid artery alteration than casual BP. With mutual adjustment for daytime and night-time BP, the latter (P < 0.0001) was more closely associated with IMT, which represents diffuse arterial thickening and arteriosclerosis, than daytime BP (P = 0.2). Night-time systolic BP variability was positively associated with carotid plaque (focal atherosclerotic lesions) independently of possible confounding factors, including night-time systolic BP (P = 0.01). A diminished nocturnal decline in systolic BP was associated with a greater IMT after adjustment for confounding factors (P = 0.03). A morning pressor surge was not associated with carotid artery alteration.

CONCLUSION

Ambulatory BP levels and BP variability were closely associated with carotid artery alteration, suggesting that these parameters are independent risk factors or predictors of carotid artery alteration.

Blood pressure control in Italy: results of recent surveys on hypertension

BACKGROUND

Blood pressure (BP) control is reported to be poor in hypertensive patients worldwide.

OBJECTIVE

BP levels, the rate of BP control, prevalence of risk factors and total cardiovascular risk were assessed in a large cohort of hypertensive patients, derived from recent surveys performed in Italy.

METHODS

Fifteen studies on hypertension, performed in different clinical settings (general population, general clinical practice, specialist outpatient clinics and hypertension centres) over the past decade were considered.

RESULTS

The overall sample included 52 715 hypertensive patients (26 315 men and 26 410 women, mean age 57.3 +/- 6.9 years). Despite the high percentage of patients on stable antihypertensive treatment (n = 36 556, 69%), mean systolic and diastolic BP levels were 147.8 +/- 8.5 and 89.5 +/- 5.2 mmHg, respectively. On the basis of the nature of the study (population surveys or clinical referrals), systolic BP levels were consistently higher than the normality threshold in both settings (142.6 +/- 12.4/84.8 +/- 3.7 mmHg and 150.4 +/- 4.6/91.9 +/- 4.1 mmHg, respectively). The BP stratification could be assessed in 40 829 individuals: 4.5% had optimal, 9.2% normal and 8.3% high-normal BP levels, however, the large majority were in grade 1 (39%) or grades 2-3 (32.6%) hypertension. In the overall sample, 55.9% of hypertensive patients had hypercholesterolemia, 28.7% were smokers, 36.4% were overweight or obese and 15.0% had diabetes mellitus. Cardiovascular risk stratification was assessed in 37 813 hypertensives: 23.2% had low, 33.9% moderate, 30.2% high and 12.7% very high added risk.

CONCLUSION

Our analysis demonstrates the persistence of poor BP control and high prevalence of risk factors, supporting the need for more effective, comprehensive and urgent actions to improve the clinical management of hypertension.

Home-measured blood pressure is more strongly associated with atherosclerosis than clinic blood pressure: the Finn–HOME Study

BACKGROUND

The aim of this study was to assess whether carotid intima-media thickness (IMT) is more strongly associated with home-measured blood pressure (BP) than clinic BP. Other risk factors associated with carotid atherosclerosis were also investigated.

METHODS

We studied a representative unselected sample of the Finnish adult population (758 subjects aged 45-74 years). Subjects included in the study underwent a clinical interview, carotid ultrasonography, and measurement of clinic BP (mean of two measurements using a mercury sphygmomanometer) and home BP (mean of 14 duplicate measurements during 1 week using a validated, automatic device). Fasting blood samples for serum lipids and glucose were drawn.

RESULTS

The Pearson correlation coefficients for carotid IMT and home/clinic BP differed significantly in favour of home measurement for systolic BP (0.34 versus 0.25, P < 0.001), diastolic BP (0.20 versus 0.07, P < 0.001) and pulse pressure (0.37 versus 0.27, P < 0.001). In a linear regression model (R = 0.32, P < 0.001), age (P < 0.001), home systolic BP (P = 0.002), serum triglycerides (P = 0.006), male sex (P = 0.009), smoking (P = 0.017), diabetes (P = 0.035), and low-density lipoprotein cholesterol (P = 0.041) were independently associated with increased IMT. The association between home BP and carotid IMT did not increase with the number of home measurements.

CONCLUSION

BP is one of the most important factors in the pathogenesis of atherosclerosis. Home-measured BP is more strongly associated with carotid atherosclerosis than clinic BP, even for a low number of measurements. These data support the application of home BP measurement in clinical practice.

Diurnal cortisol variation is associated with nocturnal blood pressure dipping

OBJECTIVE

To investigate if diurnal cortisol variation is associated with nocturnal blood pressure (BP) dipping.

METHODS

In this study, 302 healthy adults (51% female; average age 31 years) underwent 24-hour ambulatory BP assessment with BP measured randomly approximately every 20 minutes during waking hours and every hour during sleep. Salivary cortisol was obtained at five time points. Cortisol and BP have natural diurnal variations and disruptions in these diurnal variations are related to pathological conditions, such as greater risk for cardiovascular disease. A lack of a drop in cortisol from day to night and a lack of a drop in BP from waking to sleeping have both been associated with negative outcomes. It is not known, however, if diurnal variations in cortisol and BP are related, or if changes in cortisol from day to night influence BP dipping.

RESULTS

Diurnal cortisol variation was a significant predictor of BP dipping. Controlling for gender, body mass index, age, phase of menstrual cycle, sleep quality, morning cortisol, and daytime measures of the relevant cardiovascular assessments did not significantly affect the results. Cortisol variation was found to have a stronger relationship with BP dipping than any of the covariates measured.

CONCLUSION

Decreased diurnal variation in cortisol is associated with decreased diurnal variation in BP. Future studies could benefit from examining how these two variables interact in predicting disease outcomes.

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.

Evaluation of subclinical target organ damage for risk assessment and treatment in the hypertensive patients: left ventricular hypertrophy

At some point in the natural history of hypertension, the compensatory increase in left ventricular mass ceases to be beneficial. Left ventricular hypertrophy (LVH) becomes a preclinical disease and an independent risk factor for congestive heart failure, ischemic heart disease, arrhythmia, sudden death, and stroke. In addition to elevated BP, several mechanisms are involved, including body size, age, gender, race, fibrogenic cytokines, and neurohumoral factors, notably angiotensin II, which favor interstitial collagen deposition and perivascular fibrosis. These tissue changes are responsible for the insidious contractile dysfunction that is associated with LVH, consequent to decreased coronary reserve and altered diastolic ventricular filling and relaxation. The cardinal investigations are echocardiography and electrocardiography. All antihypertensive drugs regress LVH, notably those that act on the renin-angiotensin-aldosterone system, which also could target the detrimental tissue changes. Regression enhances systolic midwall performance, normalizes autonomic function, and restores coronary reserve. The resulting improvement in prognosis has enshrined the detection, prevention, and reversal of LVH in the current guidelines of hypertension management.

Guidelines for Screening of Extracranial Carotid Artery Disease: A Statement for Healthcare Professionals from the Multidisciplinary Practice Guidelines Committee of the American Society of Neuroimaging; Cosponsored by the Society of Vascular and Interventional Neurology

The aim of this new statement is to provide comprehensive and timely evidence-based recommendations on the screening for asymptomatic carotid artery stenosis in the general population and selected subsets of patients. Recommendations are included for high-risk persons in the general population; patients undergoing open heart surgery including coronary artery bypass surgery; patients with peripheral vascular diseases, abdominal aortic aneurysms, and renal artery stenosis; patients after radiotherapy for head and neck malignancies; patients following carotid endarterectomy, or carotid artery stent placement; patients with retinal ischemic syndromes; patients with syncope, dizziness, vertigo or tinnitus; and patients with a family history of vascular diseases and hyperhomocysteinemia. The recommendations are based on prevalence of disease, anticipated benefit, and concurrent guidelines from other professional organizations in selected populations.

Impact of gender on 24-h ambulatory blood pressure and target organ damage

Differences between male and female subjects in mean 24 h blood pressure (BP) values and target organ damage such as left ventricular mass (LVMASS) and intima-media thickness (IMT) of carotid arteries were explained. The study population consisted of 1,445 subjects. All subjects underwent 24 h ambulatory BP monitoring, left ventricular echocardiography and measurement of IMT of carotid arteries. Men and women did not differ in age, body mass index (BMI) and clinic BP values. Mean 24 h systolic and diastolic BP were significantly higher in men compared to women. LVMASS corrected for body surface area or height(2.7), IMT of common (MCCA) and internal (MICA) carotid arteries were found to be significantly higher in men compared to women. Analysis of covariance showed that men had significantly higher LVMASS, MCCA and MICA than women, after adjustment for BMI, age, smoking status, mean 24 h systolic and diastolic BPs, fasting serum glucose, total cholesterol and triglycerides. These findings indicate that male sex could be an important predictor of higher mean 24 h BP and target organ damage for subjects of similar BMI and clinic BP values.

Exaggerated blood pressure response to exercise is associated with carotid atherosclerosis in apparently healthy men

OBJECTIVE

Although an exaggerated systolic blood pressure (SBP) response to exercise is a predictor of future hypertension and cardiovascular mortality, the underlying mechanisms are not fully understood. We tested the hypothesis that an exaggerated SBP response is associated with carotid atherosclerosis in a cross-sectional study of 9073 healthy men (aged 47.8 +/- 8.8 years).

METHODS

Exaggerated SBP response was defined as an SBP of 210 mmHg or greater during a maximal treadmill test. Carotid atherosclerosis was defined as stenosis greater than 25% or intima-media thickness greater than 1.2 mm using B-mode ultrasonography.

RESULTS

An exaggerated SBP response was present in 375 men (4.1%). The proportion of individuals with carotid atherosclerosis in the group with an exaggerated SBP response to exercise was higher than in the group with a normal SBP response (14.4 versus 5.3%, P < 0.001). In a multivariable logistic regression model, individuals with an exaggerated SBP (>or= 210 mmHg) response to exercise had a 2.02 times [95% confidence interval (CI) 1.33-3.05] increased risk of carotid atherosclerosis compared with individuals with an SBP response of less than 210 mmHg. The highest quartile (> 61 mmHg) group of relative exercise-induced increases in SBP showed a 1.57 (95% CI 1.18-2.08) greater risk of carotid atherosclerosis compared with individuals in the lowest quartile (< 38 mmHg) in the adjusted model.

CONCLUSIONS

These results suggest that an exaggerated SBP response to exercise is strongly associated with carotid atherosclerosis, independent of established risk factors in healthy men. It may be an important factor in evaluating hypertension related to target-organ damage.

Dynamics of the circadian blood pressure profiles after renal transplantation

BACKGROUND

Abnormalities of diurnal blood pressure (BP) rhythm ("nondipping") are well-described in dialysis patients, and have prognostic importance. It is controversial whether successful renal transplantation (RTx) improves diurnal BP rhythm. To date, no study has attempted to define and model the evolution of diurnal BP rhythm profiles from dialysis to engraftment, focusing on the immediate (4-6 weeks) and medium-term (>1 year) postengraftment periods.

METHODS

To test if kidney transplantation normalizes the BP profile, ambulatory blood pressure monitoring (ABPM) was performed in 20 living related transplants (age, 30.3+/-5.1 years; 11 males, on dialysis for 25.6 months) 1 month preRTx and repeated 1 month and >1 year (ABPM3) after successful RTx. Dipping was defined as a sleep-to-awake ratio>0.92 (for systolic BP) and >0.90 (for diastolic BP).

RESULTS

PreRTx only 15% patients were dippers. At 1 month postRTx (creatinine clearance, 65.8 ml/min), all patients were complete nondippers. However, after >1 year postRTx (creatinine clearance, 70.4 ml/min), 40% were now dippers. Most importantly, overall, 30% of the patients improved significantly their circadian rhythm (35.3% of the initial preRTx nondippers). Despite successful renal transplantation, 55% patients maintained unchanged their nondipping profile throughout all three ABPM recordings. The only determinants of "long-term" postRTx circadian rhythm are the contemporary level of the renal function and the baseline, dialysis dipping profile: SBP3 sleep-to-awake ratio is related with serum creatinine3 (r=0.58, P=0.001), creatinine clearance (r=-0.41, P=0.036) and SBP1 sleep-to-awake ratio (r=0.48, P=0.034); similarly DBP3 sleep-to-awake ratio is related with serum creatinine3 (r=0.63, P=0.001), creatinine clearance (r=-0.471, P=0.036) and SBP1 sleep-to-awake ratio (r=0.53, P=0.016). In all, 57% of the variance in dipping status can be attributed and explained by the contribution of renal function and initial circadian variability.

CONCLUSIONS

Half of the nondipper dialysis patients maintain a permanently abnormal circadian rhythm, despite successful RTx. In the short term, RTx is associated with a highly abnormal diurnal profile, exclusively related to ciclosporin dose and levels. However, in the longer term, renal transplantation leads to a significant improvement of the circadian blood pressure profile, influenced by the renal function level and by the pretransplantation dipping profile.

Riskard 2005. New tools for prediction of cardiovascular disease risk derived from Italian population studies

BACKGROUND AND AIM

The need to update tools for the estimate of cardiovascular risk prompted the "Gruppo di Ricerca per la Stima del Rischio Cardiovascolare in Italia" to produce a new chart and new software called Riskard 2005.

METHODS AND RESULTS

Data from 9 population studies in 8 Italian regions, for a grand total of 17,153 subjects (12,045 men and 5,108 women) aged 35-74 and for a total exposure of about 194,000 person/years were available. A chart for the estimate of cardiovascular risk (major coronary, cerebrovascular and peripheral artery disease events) in 10 years was produced for men and women aged 45-74 free from cardiovascular diseases. Risk factors employed in the estimate were sex, age (6 classes), systolic blood pressure (4 classes), serum cholesterol (5 classes), diabetes, and cigarette smoking (4 classes). Estimates were produced for absolute risk and for relative risk, the latter against levels expected in the general population that produced the risk functions. Software was produced for the separate estimate of major coronary, cerebrovascular and cardiovascular events (the latter made by coronary, cerebrovascular and peripheral artery disease of atherosclerotic origin) for follow-up at 5, 10 or 15 years, in men a women aged 35-74 years at entry and free from cardiovascular diseases. Risk factors employed here were sex, age, body mass index, mean physiological blood pressure, HDL cholesterol, non-HDL cholesterol, cigarette smoking, diabetes and heart rate. The output is based on several indicators: absolute risk, relative risk (as defined above), ideal risk (for a very favourable risk profile), biological age of risk, comparisons among the above indicators, the percent contribution of risk factors to the excess of estimated risk above the level of the ideal risk, and the description of trends in risk estimate in relation to repeated measurements.

CONCLUSIONS

These tools represent progress compared to similar tools produced some years ago by the same Research Group.

Twenty-four-hour ambulatory blood pressure and duration of hypertension as major determinants for intima-media thickness and atherosclerosis of carotid arteries

The relationship between time factors of elevated blood pressure (BP) and carotid atherosclerosis (CA) is still unclear. The associations between time-weighted average 24 h ambulatory systolic BP (TWA-SBP), duration of hypertension in years (hypertension-year), and CA were investigated in a petrochemical company sample of 95 executives and 91 gender- and age-matched non-executives employees. Intima-media thickness (IMT) and plaque scores of extracranial carotid artery (ECCA) were determined bilaterally by high-resolution B-mode ultrasound. The determinants of segment-specific carotid IMT and odds ratios for CA, in terms of thicker IMT (IMT > or = 75th percentile) and ECCA score > or = 3, were evaluated by multivariate regression analysis. Results revealed TWA-SBP and hypertension-year were two major determinants of IMT at common carotid artery (CCA) and carotid bulb by using mixed regression models. However, TWA-DBP was a negative determinant of IMT at CCA and carotid bulb. Meanwhile, the executives were found to be a negative association with IMT at carotid bulb. Measurements at both internal carotid artery and bulb identified duration of diabetes mellitus as significant determinant of IMT. After controlling covariates, multivariate logistic regression analysis identified TWA-SBP and hypertension-year as the important determinants for thicker IMT and ECCA > or = 3. And, TWA-DBP was found as a negative determinant for CA. In conclusion, both TWA-SBP and hypertension-year were two major determinants for carotid IMT and CA, which seem to imply that both short-term and long-term durations of elevated BP are probably crucial in the pathogenesis of CA.

Cardiac structural and functional changes during long-term antihypertensive treatment with lacidipine and atenolol in the European Lacidipine Study on Atherosclerosis (ELSA)

OBJECTIVES

To evaluate and correlate the effects of long-term antihypertensive treatment on left ventricular (LV) mass and carotid structural changes in a large group of essential hypertensive patients, participating in the European Lacidipine Study on Atherosclerosis (ELSA).

DESIGN

In four (Brescia, Glasgow, Naples and Pisa) of 23 centres participating in the ELSA study, an echocardiographic examination was performed at baseline and repeated, until the end of the 4-year study, in essential hypertensive patients, followed-up for carotid quantitative ultrasound examination of intima-media thickness (IMT), after random allocation to treatment with either lacidipine or atenolol (and added hydrochlorothiazide, as required for control of blood pressure).

METHODS

M-mode, two-dimensional guided echocardiography was used to measure left ventricular (LV) wall thickness and dimensions, from which LV mass was calculated, using an anatomically validated formula (Penn Convention) and indexed to body surface area (left ventricular mass index, LVMI). The echocardiographic tracings were blindly evaluated in a single reading centre (Brescia). Bilateral IMT was measured at the site of common carotid and bifurcation far walls (CBMmax).

RESULTS

At baseline, cardiac and carotid ultrasound scans were available in 278 patients (mean age 54 +/- 7 years, 57% males, 22% obese). A significant correlation was observed between baseline LVMI and CBMmax (r = 0.22, P < 0.001), independent of age. In multivariate analysis, CBMmax and mean 24-h pulse pressure were most strongly associated with baseline LVMI. A significant reduction in LVMI was observed both during lacidipine (n = 96) (-12.5% reduction) and atenolol (n = 78) (-13.9% reduction) treatments (up to 4 years) (P < 0.001 for both, without significant differences between treatments). Changes in LVMI were not related to changes in carotid wall thickness. In multivariate analysis, baseline LV mass and mean 24-h systolic blood pressure changes were significantly associated with changes in LV mass.

CONCLUSIONS

In this large, long-term controlled study, antihypertensive treatment with atenolol or lacidipine was accompanied by a similar and significant decrease in LV mass. Treatment-induced changes in LV mass were related to baseline LV mass and changes in 24-h mean systolic blood pressure, without any correlation with changes in carotid structure. In the whole ELSA population, carotid IMT changes have been shown to be unrelated to blood pressure reduction, but significantly influenced by the type of antihypertensive treatment.

Protective Effects of an Angiotensin II Receptor Blocker and a Long-Acting Calcium Channel Blocker against Cardiovascular Organ Injuries in Hypertensive Patients

The purpose of this study is to compare the long-term effects of an angiotensin II receptor blocker (ARB) and a long-acting calcium channel blocker (CCB) on left ventricular geometry, hypertensive renal injury and a circulating marker of collagen synthesis in hypertensive patients. Patients with essential hypertension (24 men and 19 women; age, 37-79 years) were treated with a long-acting CCB, amlodipine (AML; 2.5-7.5 mg once daily) for 6 months. Then, AML was switched to an ARB, candesartan (CS; 4-12 mg once daily), in 22 patients (CS group), while AML was continued in the remaining 21 patients for another 6 months (AML group). At the end of each treatment period, ambulatory blood pressure monitoring (ABPM), echocardiography and sampling of blood and urine were performed. The average office blood pressure during the latter period was comparably controlled in the AML and the CS groups (AML: 130 +/- 8/87 +/- 7 mmHg; CS: 133 +/- 11/ 88 +/- 7 mmHg), while the average systolic blood pressure of 24-h ABPM was significantly lower in the AML than in the CS group (127 +/- 9 vs. 133 +/- 14 mmHg, p<0.05). Consequently, the left ventricular mass index was significantly decreased in the AML group (102 +/- 18 to 92 +/- 12 g/m2, p<0.05), while the change was insignificant in the CS group (103 +/- 25 to 98 +/- 21 g/m2). On the other hand, plasma procollagen I C-terminal peptide (PICP), a marker of collagen synthesis, was lowered by CS (86 +/- 21 to 70 +/- 21 ng/ml, p<0.01), but was not significantly affected by AML (80 +/- 127 to 74 +/- 91 ng/ml). CS reduced urinary albumin excretion (57 +/- 123 to 26 +/- 33 mg/g creatinine, p<0.05), but AML did not bring about significant changes (85 +/- 27 to 73 +/- 19 mg/g creatinine). The results suggested that long-acting CCBs are effective in improving left ventricular hypertrophy by controlling 24-h blood pressure, while ARBs possess protective effects against cardiovascular fibrosis and renal injury beyond their antihypertensive effects.

Metabolic syndrome amplifies the age-associated increases in vascular thickness and stiffness

OBJECTIVES

We sought to evaluate whether the clustering of multiple components of the metabolic syndrome (MS) has a greater impact on these vascular parameters than individual components of MS.

BACKGROUND

Intima-media thickness (IMT) and vascular stiffness have been shown to be independent predictors of adverse cardiovascular events. The MS is defined as the clustering of three or more of the cardiovascular risk factors of dysglycemia, hypertension, dyslipidemia, and obesity.

METHODS

Carotid IMT and stiffness were derived via B-mode ultrasonography in 471 participants from the Baltimore Longitudinal Study on Aging, who were without clinical cardiovascular disease and not receiving antihypertensive therapy.

RESULTS

The MS conferred a disproportionate increase in carotid IMT (+16%, p < 0.0001) and stiffness (+32%, p < 0.0001), compared with control subjects. Multiple regression models, which included age, gender, smoking, low-density lipoprotein, as well as each individual component of MS as continuous variables, showed that MS was an independent determinant of both IMT (p = 0.002) and stiffness (p = 0.012). The MS was associated with a greater prevalence of subjects whose values were in the highest quartiles of IMT, stiffness, or both.

CONCLUSIONS

Even after taking into account each individual component of MS, the clustering of at least three of these components is independently associated with increased IMT and stiffness. This suggests that the components of MS interact to synergistically impact vascular thickness and stiffness. Future studies should examine whether the excess cardiovascular risk associated with MS is partly mediated through the amplified alterations in these vascular properties.

Cardiovascular target organ damage in essential hypertensives with or without reproducible nocturnal fall in blood pressure

OBJECTIVE

The clinical significance of classifying patients as dippers and non-dippers on the basis of a single period of ambulatory blood pressure monitoring (ABPM) has been questioned. The aim of this study was to evaluate the relationship between nocturnal dipping status, defined on the basis of two periods of ABPM, and cardiac and extracardiac target organ damage in essential hypertension.

METHODS

A total of 375 never-treated essential hypertensive patients [mean 24-h blood pressure (BP) > or = 125/80 mmHg; mean +/- SD age 45.9 +/- 11.9 years] referred for the first time to our outpatient clinic underwent the following procedures: (i) repeated clinic BP measurements; (ii) blood sampling for routine chemistry examinations; (iii) 24-h urine collection for microalbuminuria; (iv) ABPM over two 24-h periods within 4 weeks; (v) echocardiography; and (vi) carotid ultrasonography.

RESULTS

A reproducible nocturnal dipping (decrease in BP > 10% from mean daytime BP in both ABPM periods) and non-dipping profile (decrease in BP < or = 10% in both ABPM periods) was found in 199 (group I) and 79 patients (group II), respectively; 97 patients (group III) had a variable dipping profile. The three groups did not differ with regard to age, gender, body mass index, clinic BP, 48-h BP and heart rate. Left ventricular mass index, interventricular septum thickness, left atrium and aortic root diameters were significantly higher in group II compared with group I (mean +/- SD 108.5 +/- 19.5 versus 99.7 +/- 19.6 g/m, P < 0.05; 9.3 +/- 0.9 versus 9.1 +/- 0.9 mm, P < 0.05; 33.6 +/- 3.6 versus 32.2 +/- 3.7 mm, P < 0.01; 36.9 +/- 4.6 mm versus 35.5 +/- 4.6, P < 0.05, respectively). The smaller differences seen between groups II and III and between groups I and III were not statistically significant. The prevalence of left ventricular hypertrophy (defined as a left ventricular mass index > 134 g/m in men and > 110 g/m in women) was greater in group II (19%) than in group I (6%) (P < 0.05), whereas the differences between groups II and III and between groups I and III did not reach statistical significance. Differences among the three groups in the prevalence of carotid structural alterations (such as carotid plaques or intima-media thickening) were not statistically significant, and microalbuminuria had a similar prevalence in all three groups.

CONCLUSIONS

Despite similar clinic and 48-h BP values, never-treated hypertensive patients with a persistent non-dipper pattern showed a significantly greater extent of cardiac structural alterations compared with subjects with a reproducible dipping pattern, but not those with a variable BP nocturnal profile. A non-dipping pattern diagnosed on two concordant ABPM periods instead of a single monitoring therefore represents a clinical trait associated with more pronounced cardiac abnormalities. Finally, in non-dipping middle-aged hypertensives, echocardiography appears to provide a more accurate risk stratification than carotid ultrasonography or microalbuminuria.

Home Blood Pressure Is a Better Predictor of Carotid Atherosclerosis than Office Blood Pressure in Community-Dwelling Subjects

An increase in the thickness of the intima-media (IMT) of the carotid artery is associated with an increased risk of cardiovascular morbidity and mortality. Hypertension is one of the underlying mechanisms for the progression of carotid atherosclerosis. However, office blood pressure (BP) has been shown to have only a weak association with carotid IMT. Since self-measured home BP has less variation than office BP, home BP could be a better predictor of carotid atherosclerosis. To explore this hypothesis, we compared the relationships between carotid IMT and office BP or home BP in a community-dwelling population. One-hundred and one community residents, aged 50 years or older and not taking any medication, were enrolled in this study. Morning home BP was measured according to the guidelines of the Japanese Society of Hypertension. The results were recorded for 2 weeks and averaged. Carotid atherosclerosis was defined as IMT > or =0.80 mm, which corresponds to the first quartile. Home systolic BP showed a more significant association with carotid IMT (r=0.422, p <0.0001) than with office systolic BP (r=0.021, p=0.027). Logistic regression analysis for the presence of carotid atherosclerosis further showed that the relative risk of hypertension defined using home BP (> or =135/85 mmHg) was 6.3 (95% confidence interval [CI]: 2.0 to 19.6), while that using office BP was 1.5 (95% CI: 0.5 to 4.2). These results suggest that home BP is a better predictor of the development of carotid atherosclerosis than office BP.

Adrenergic mechanisms and remodeling of subcutaneous small resistance arteries in humans

BACKGROUND

Vascular structural alterations in small resistance arteries of patients with essential hypertension (EH) are mostly characterized by inward eutrophic remodeling. In fact, no difference in the smooth muscle cell volume (CV) between normotensive subjects (NT) and essential hypertensive patients was observed. However, experimental models of hypertension with chronic infusion of agonists of adrenergic receptors were characterized by the presence of smooth muscle cell hypertrophy or hyperplasia. Recently, we have observed the presence of vascular smooth muscle cell hypertrophy in patients with renovascular hypertension.

OBJECTIVE

The aim of the study to investigate the structural characteristics of subcutaneous small resistance arteries of NT, of EH, and of patients with phaeochromocytoma (Phaeo).

PATIENTS AND METHODS

Thirty Phaeo, 30 NT and 30 EH were included in the study. A biopsy of subcutaneous fat was taken from all subjects. Small resistance arteries (relaxed diameter 160-280 microm) were dissected and mounted on a micromyograph and the media : lumen ratio was calculated. In nine Phaeo, nine NT and 13 EH the cell volume was measured by an unbiased stereological principle, the 'disector' method. RESULTS No difference in smooth muscle cell volume was observed between groups. However, inward remodeling in Phaeo was less marked than in EH, although the increase in media : lumen ratio was similar compared with NT. However, the lack of changes in media cross-sectional area, compared with NT, suggest that there has been little hypertrophy, the changes observed thus being eutrophic.

CONCLUSIONS

Our data show, based on a reasonably large sample, that a pronounced activation of the adrenergic system is not associated with vascular smooth muscle cell hypertrophy or hyperplasia in humans. It is therefore possible that adrenergic mechanisms may have a relevant role in the development of eutrophic remodeling in small vessels.

Left ventricular structural and functional characteristics in Cushing's syndrome

OBJECTIVES

This study was designed to evaluate left ventricular (LV) anatomy and function in patients with Cushing's syndrome.

BACKGROUND

A high prevalence of LV hypertrophy and concentric remodeling has been reported in Cushing's syndrome, although no data have been reported on LV systolic and diastolic function.

METHODS

Forty-two consecutive patients with Cushing's syndrome and 42 control subjects, matched for age, gender, and blood pressure, were studied. Left ventricular mass index (LVMI) and relative wall thickness (RWT) were measured by echocardiography, endocardial and midwall fractional shortening (FS) were assessed, and diastolic filling was measured by Doppler transmitral flow.

RESULTS

The RWT was significantly greater in Cushing patients than in controls. Left ventricular hypertrophy and concentric remodeling were observed in 10 and 26 patients with Cushing's syndrome, respectively. In Cushing patients, midwall FS was significantly reduced compared with controls (16.2 +/- 3% vs. 21 +/- 4.5%, p = 0.01). The ratio of transmitral E and A flow velocities was reduced and E deceleration time was prolonged in Cushing patients compared with controls (p = 0.03 and p < 0.001, respectively).

CONCLUSIONS

In patients with Cushing's syndrome, cardiac structural changes are associated with reduced midwall systolic performance and with diastolic dysfunction that may contribute to the high risk of cardiovascular events observed in these patients.

Non-dipper treated hypertensive patients do not have increased cardiac structural alterations

BACKGROUND

Non-dipping pattern in hypertensive patients has been shown to be associated with an excess of target organ damage and with an adverse outcome. The aim of our study was to assess whether a reduced nocturnal fall in blood pressure (BP), established on the basis of a single 24-h BP monitoring, in treated essential hypertensives is related to more prominent cardiac alterations.

METHODS

We enrolled 229 treated hypertensive patients attending the out-patient clinic of our hypertension centre; each patient was subjected to the following procedures : 1) clinic BP measurement; 2) blood and urine sampling for routine blood chemistry and urine examination; 3) standard 12-lead electrocardiogram; 4) echocardiography; 5) ambulatory BP monitoring (ABPM). For the purpose of this study ABPM was carried-out in three subgroups with different clinic BP profile: 1) patients with satisfactory BP control (BP < 140/90 mmHg; group I, n = 58); 2) patients with uncontrolled clinic BP (clinic BP values > or = 140 and/or 90 mmHg) but lower self-measured BP (< 20 mmHg for systolic BP and/or 10 mmHg for diastolic BP; group II, n = 72); 3) patients with refractory hypertension, selected according to WHO/ISH guidelines definition (group III, n = 99). Left ventricular hypertrophy (LVH) was defined by two gender-specific criteria (LV mass index > or = 125/m2 in men and 110 g/m2 in women, > or = 51/gm2.7 in men and 47/g/m2.7 in women).

RESULTS

Of the 229 study participants 119 (51.9%) showed a fall in SBP/DBP < 10% during the night (non-dippers). The prevalence of non-dippers was significantly lower in group I (44.8%) and II (41.6%) than in group III (63.9%, p < 0.01 III vs II and I). The prevalence of LVH varied from 10.3 to 24.1% in group I, 31.9 to 43.1% in group II and from 60.6 to 67.7% in group III (p < 0.01, III vs II and I). No differences in cardiac structure, analysed as continuous variable as well as prevalence of LVH, were found in relationship to dipping or non-dipping status in the three groups.

CONCLUSIONS

In treated essential hypertensives with or without BP control the extent of nocturnal BP decrease is not associated with an increase in LV mass or LVH prevalence; therefore, the non-dipping profile, diagnosed on the basis of a single ABPM, does not identify hypertensive patients with greater cardiac damage.

Carotid Intima-Media Thickness Is Correlated with Impairment of Coronary Flow Reserve in Hypertensive Patients without Coronary Artery Disease

Hypertensive individuals occasionally experience angina-like chest pain despite having angiographically normal coronary arteries, and the etiology of this phenomenon has been suggested to be associated with depressed coronary flow reserve (CFR). Carotid intima-media thickness (IMT) assessed by ultrasound is correlated with not only cerebrovascular disease but also coronary artery disease and left ventricular hypertrophy (LVH). The aim of our study was to investigate the association between CFR and carotid IMT in patients with essential hypertension. We performed transthoracic Doppler recording of diastolic coronary flow velocity in the left anterior descending coronary artery at baseline and after maximal vasodilation by adenosine triphosphate infusion in 24 normotensive subjects and 125 hypertensive patients. CFR was defined as the ratio of hyperemic to basal averaged peak coronary flow velocity. Common cardiovascular risk factors, left ventricular mass index (LVMI), relative wall thickness (RWT), and carotid IMT were evaluated. The CFR of hypertensive patients (2.55 +/- 0.52) was significantly decreased compared with that of normotensive subjects (3.15 +/- 0.45). CFR showed a significant correlation with age, systolic blood pressure, RWT, and carotid IMT. Stepwise regression analysis revealed that, among carotid IMT, LVMI and RWT, only carotid IMT was a strong and independent parameter for predicting CFR in hypertensive patients. In conclusion, B-mode ultrasound scanning of the carotid artery seemed to be of clinical value in the screening of patients with LVH and impaired microcoronary circulation. These associations may explain the links between cardiac and cerebrovascular involvements in patients with 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.

Intima-media thickness of the common carotid arteries is related to coronary atherosclerosis and left ventricular hypertrophy in older adults

Increased intima-media thickness (IMT) of the common carotid arteries is related to generalized atherosclerosis and increased risk of future myocardial infarction and cerebrovascular disease. An association between IMT and the presence of coronary artery disease (CAD) has been documented, but controversial data have been found about the relation between increased IMT and the extent of CAD. An association between carotid atherosclerosis and cardiac remodeling has also been reported. It is still unclear whether increased IMT of the common carotid arteries might be associated with prevalent cardiovascular disease in older adults. This study included 70 patients, 37 with CAD and 33 matched for age and gender without CAD. All patients underwent a baseline clinical examination, B-mode ultrasound of the carotid arteries, and echocardiography. The authors evaluated the possible association between increased IMT with the presence and extent of CAD and the presence of left ventricular hypertrophy (LVH). The patients with CAD had significantly increased IMT compared to patients without CAD. IMT was found to increase with the number of coronary vessels affected, after adjustment for age, gender, hypertension, hypercholesterolemia, diabetes mellitus, and smoking habits. The test for trend was highly significant (p<0.001). Patients with LVH had significantly increased IMT as compared with patients without LVH. IMT of the common carotid arteries was increased in the presence of CAD and increased with the number of coronary vessels diseased. Second, the authors found that IMT of the common carotid arteries was significantly increased in patients with LVH. Increased IMT, as an indicator of subclinical cardiovascular disease, may help to identify patients who would benefit from aggressive therapeutic measures.

Structural changes in small resistance arteries and left ventricular geometry in patients with primary and secondary hypertension

OBJECTIVE

To prospectively evaluate the interrelationships between left ventricular (LV) geometry and structural characteristics of the vessel wall in small resistance arteries in patients with consecutive primary and secondary hypertension.

METHODS

In 14 patients with phaeochromocytoma, 12 with primary aldosteronism, 25 with renovascular, 25 with essential hypertension and 12 normotensive controls, an echocardiographic study for the measurement of LV mass index and relative wall thickness (RWT) was performed. Morphological characteristics of small resistance arteries (relaxed diameter < 300 microm) were directly evaluated by a micromyographic technique.

RESULTS

A total of 25 patients had normal LV mass and geometry, 28 patients had normal RWT (< 0.45) and 23 patients had a RWT >or= 0.45; all normotensive subjects had normal LV mass and geometry. Media to lumen ratio (M/L) in subcutaneous small arteries was greater in hypertensive patients with concentric LV hypertrophy in respect to normotensives (ANOVA P = 0.01) and hypertensives with normal LV geometry (ANOVA P = 0.05). In the whole group of hypertensive patients the correlation coefficient between M/L and LV mass index was 0.33 (P < 0.05); the correlation coefficient between M/L and RWT was 0.46 (P < 0.01) and it was higher in primary aldosteronism (r = 0.67) and renovascular hypertension patients (r = 0.46).

CONCLUSIONS

A close relation between morphology of subcutaneous small resistance arteries and LV geometric patterns may be observed in hypertensive patients; this relationship is more evident when the renin-angiotensin-aldosterone system is activated.

Left ventricular concentric remodelling and extracardiac target organ damage in essential hypertension

Left ventricular (LV) concentric remodelling is an adaptive change in cardiac geometry frequently observed in arterial hypertension. This study was addressed to investigate the extent of extracardiac target organ damage (TOD) in patients with LV concentric remodelling. Two groups of never-treated essential hypertensives, 31 with normal LV geometry (group I, relative wall thickness: 0.39) and 31 with LV concentric remodelling (group II, relative wall thickness: 0.47) matched for age, sex, body mass index and mean 24-h systolic blood pressure (BP), were included in the study. They underwent clinical and laboratory examination, 24-h ambulatory BP monitoring (ABPM), 24-h urinary collection for microalbuminuria, non-mydriatic photography of ocular fundi, echocardiography and carotid ultrasonography. In both groups age (I: 51 +/- 11 years; II: 51 +/- 11 years), body mass index (I: 25 +/- 3 kg/m(2); II: 26 +/- 3 kg/m(2)), clinic and 24-h ABPM values (I: 149 +/- 11/95 +/- 8, 142 +/- 11/91 +/- 7 mm Hg; II: 150 +/- 11/98 +/- 9, 142 +/- 12/92 +/- 9 mm Hg) were similar by design. There were no differences between patients with normal LV geometry and with LV concentric remodelling in LVM index (97 +/- 16 vs 99 +/- 16), carotid intima-media thickness (0.7 +/- 0.02 vs 0.7 +/- 0.02) and carotid plaques prevalence (35% vs 35%). Furthermore, no significant differences among the two groups were found in the prevalence of retinal changes and microalbuminuria. These results suggest that in hypertensive patients with similar BP and LVMI levels, LV concentric remodelling is not associated with more prominent TOD.

Comparison of the effects of amlodipine and losartan on 24-hour ambulatory blood pressure in hypertensive patients

Effects of amlodipine (AML), a long-acting calcium antagonist, and losartan (LOS), an angiotensin II receptor antagonist, on 24-hr blood pressure profile were compared in 15 patients with essential hypertension. After 4 weeks of placebo period, the patients were treated with AML or LOS in a random crossover design for 12-16 weeks each. Either drug was given once daily at 0800 and the doses were titrated so that the office blood pressure was reduced lower than 140/90mmHg. At the end of each period, 24-hr blood pressure was monitored. Average office blood pressure was lowered from 158 +/- 2/ 98 +/- 2 mmHg to 134 +/- 1/87 +/- 1 mmHg by AML and 134 +/- 2/88 +/- 1 mmHg by LOS. Average 24-hr blood pressure was also reduced from 144 +/- 3/ 92 +/- 2 mmHg to 131 +/- 2/84 +/- 2 mmHg by AML and 135 +/- 3/85 +/- 2 mmHg by LOS. The averaged 24-hr systolic blood pressure was significantly lower in AML than in LOS (p < 0.05). Then, the 24-hr blood pressure was analyzed for four segments; morning (0530-0900 h), daytime (0930-1800 h), evening (1830-2300 h) and night (2330-0500 h). Although the daytime blood pressure was comparable between AML and LOS, systolic blood pressure in the evening and morning hours were lower in AML than in LOS (133 +/- 2 vs. 138 +/- 3mmHg,p<0.01; 129 +/- 3 vs. 134 +/- 4,p<0.05). Troughtopeakratio of antihypertensive effect on systolic blood pressure was significantly greater in AML than in LOS (62 +/- 5% vs. 55 +/- 4%, p < 0.05). Either drug did not cause reflective increase in pulse rate over 24 hours. These results suggest that both AML and LOS are equally effective in lowering daytime blood pressure without eliciting reflex tachycardia, however, the antihypertensive effect of AML lasts longer than that of LOS. Such information seems important to achieve 24-hr blood pressure control using these drugs.

Night time blood pressure and cardiovascular structure in a middle-aged general population in northern Italy: the Vobarno Study

The aim was to determine, in a cross-sectional study, the relation between structural alterations in the heart and carotid arteries, and blood pressure (BP) changes from day to night time, measured by ambulatory BP (ABP). In 225 untreated subjects (107 F, 118 M, age range 48-64 years) and 59 treated subjects (24 M, 35 F, age range 50-64), living in a small town of northern Italy (Vobarno, Brescia) carotid intima media thickness as well as the occurrence of plaque, were evaluated by ultrasound. Echocardiographic left ventricular (LV) mass was measured according to the Penn Convention. BP was determined by clinic measurement and by 24-h non-invasive ABP monitoring. Subjects were divided in two groups, according to the decrease of night time systolic BP (SBP) "dippers" (SBP decreased by at least 10% during night time) and "non-dippers" (decrease of night time SBP <10%). The intima-media thickness in the common carotid, in the carotid bifurcation, in the internal carotid artery and average intima-media thickness were significantly greater in untreated non-dippers as compared with dipper subjects (ANOVA P < 0.05). A significantly higher prevalence of plaque was observed in untreated non-dippers as compared with dippers (P = 0.002). After adjusting for age, sex, 24-h SBP, and smoking, IMT in the carotid bifurcation and average intima-media thickness remained significantly greater in non-dipper subjects (P < 0.05 for all comparisons). No significant differences in LV mass were observed between dippers and non-dipper subjects. In conclusion, in a general population of unselected middle-aged subjects, night time BP values, among other risk factors, seem to represent an important determinant of carotid wall structure.