Long-term prognostic impact of repeated measurements over 1 year of pulse pressure and systolic blood pressure in the elderly

Systolic blood pressure (SBP) and pulse pressure (PP) have been identified in western industrialized countries as major predictors of cardiovascular events in the elderly on the basis of measurements taken at a single visit. Considering the wide variability of blood pressure (BP) in older people, this study set out to assess the prognostic significance of measurements of SBP and PP taken over several months according to a monitoring scheme mimicking routine care. A total of 444 Italian general practitioners enrolled a cohort of 3858 unselected elderly outpatients and followed them up for 10 years. BP was recorded at recruitment, 1 week later and at quarterly visits during the first year. The average BP of these six visits was used to define the patient's BP status. During the 10-year follow-up, 1561 participants died, 709 from cardiovascular diseases. Proportional hazard regression analysis, adjusted for all main prognostic factors including antihypertensive treatment, showed that for each 10-mmHg increment in SBP and PP there were, respectively, 5 and 9% increases in risk for total mortality (TM) and 9 and 13% increases in risk for cardiovascular mortality (CVM) (all P < 0.01). However, including both SBP and PP in the model, only PP showed an independent, significant relationship with TM and CVM. In conclusion, prognostic information based on repeated measurements of PP is stronger than that given by SBP and consequently should be recommended in the definition of cardiovascular risk in the elderly.

Effects of low-dose aspirin on clinic and ambulatory blood pressure in treated hypertensive patients. Collaborative Group of the Primary Prevention Project (PPP)--Hypertension study

Nonsteroidal antiinflammatory drugs may affect blood pressure (BP) control in hypertensive patients receiving drug treatment, but data on the effects of low-dose aspirin are scanty. This study assessed the effects of chronic treatment with low doses of aspirin (100 mg/day) on clinic and ambulatory systolic (SBP) and diastolic (DBP) BP in hypertensives on chronic, stable antihypertensive therapy. The study was conducted in the framework of the Primary Prevention Project (PPP), a randomized, controlled factorial trial on the preventive effect of aspirin or vitamin E in people with one or more cardiovascular risk factors. Fifteen Italian hypertension units studied 142 hypertensive patients (76 men, 66 women; mean age 59 +/- 5.9 years) treated with different antihypertensive drugs: 71 patients were randomized to aspirin and 71 served as controls. All patients underwent a clinic BP evaluation with an automatic sphygmomanometer and a 24-h ambulatory BP monitoring, at baseline and after 3 months of aspirin treatment. At the end of the study the changes in clinic SBP and DBP were not statistically different in treated and untreated subjects. Ambulatory SBP and DBP after 3 months of aspirin treatment were similar to baseline: deltaSBP -0.5 mmHg (95% confidence intervals [CI] from -1.9 to +2.9 mm Hg) and deltaDBP -1.1 mm Hg (95% CI from -2.5 to +0.3 mm Hg). The pattern was similar in the control group. No interaction was found between aspirin and the most used antihypertensive drug classes (angiotensin converting enzyme inhibitors and calcium antagonists). Despite the relatively small sample size our results seem to exclude any significant influence of low-dose aspirin on BP control in hypertensives under treatment.

Effects of vitamin E on clinic and ambulatory blood pressure in treated hypertensive patients. Collaborative Group of the Primary Prevention Project (PPP)--Hypertension study

A randomized controlled open trial studied the effect of vitamin E supplementation (300 mg/day) on clinic and 24-h ambulatory blood pressure (BP) in 142 treated hypertensive patients. After 12 weeks, clinic BP decreased whether or not patients were randomized to vitamin E. Ambulatory BP showed no change in systolic BP and a small decrease in diastolic BP (-1.6 mm Hg, 95% confidence intervals from -2.8 to -0.4 mm Hg), approaching statistical significance in comparison to the control group (P = .06). Vitamin E supplementation thus seems to have no clinically relevant effect on BP in hypertensive patients already under controlled treatment.

The long-term prognostic significance of repeated blood pressure measurements in the elderly: SPAA (Studio sulla Pressione Arteriosa nell'Anziano) 10-year follow-up

BACKGROUND

In young and middle-aged people, both systolic (SBP) and diastolic (DBP) blood pressure have a continuous, strong, and independent relationship with subsequent cardiovascular morbidity and mortality. These relationships are not well documented in older people and, until now, studies in the elderly do not provide homogeneous results on the importance of DBP compared with SBP as a cardiovascular risk factor.

OBJECTIVE

To determine whether SBP and DBP are independent indicators of mortality risk in the elderly.

DESIGN

An observational prospective cohort study to analyze the long-term prognostic significance of repeated SBP and DBP measurements in the elderly.

PATIENTS AND METHODS

A total of 3858 outpatients 65 years or older (mean age [SD], 72.9 [4.9] years, 43.5% men) were selected randomly by 444 Italian National Health Service general practitioners in 1983. The population was followed up for 10 years. Crude and adjusted incidence rates of total and cardiovascular mortality were analyzed for classes of SBP and DBP based on the values recorded at the 2 initial visits 1 week apart and those measured during the first 12 months of follow-up.

RESULTS

During the 10-year follow-up, 74 patients (1.9%) were lost to follow-up and 1561 (41.3%) died, 709 (45.4% of all deaths) from cardiovascular causes. A positive continuous, graded, strong, and independent association was observed with both total (P<.001) and cardiovascular (P<.001) mortality for SBP but not for DBP. The pattern was similar in both sexes, in persons younger and older than 75 years, regardless of preexisting cardiovascular diseases, and whether they had been receiving antihypertensive treatment at baseline. There was no J-shaped mortality curve in the subjects with the lowest SBP and DBP.

CONCLUSIONS

These findings suggest that SBP, but not DBP, is a strong, positive, continuous, independent indicator of mortality risk in the elderly and should be stressed much more than DBP in the diagnosis and treatment of hypertension in this age group.

A computer-driven approach to PCR-based differential screening, alternative to differential display

MOTIVATION

Polymerase chain reaction (PCR)-based RNA fingerprinting is a powerful tool for the isolation of differentially expressed genes in studies of neoplasia, differentiation or development. Arbitrarily primed RNA fingerprinting is capable of targeting coding regions of genes, as opposed to differential display techniques, which target 3' non-coding cDNA. In order to be of general use and to permit a systematic survey of differential gene expression, RNA fingerprinting has to be standardized and a number of highly efficient and selective arbitrary primers must be identified.

RESULTS

We have applied a rational approach to generate a representative panel of high-efficiency oligonucleotides for RNA fingerprinting studies, which display marked affinity for coding portions of known genes and, as shown by preliminary results, of novel ones. The choice of oligonucleotides was driven by computer simulations of RNA fingerprinting reverse transcriptase (RT)-PCR experiments, performed on two custom-generated, non-redundant nucleotide databases, each containing the complete collection of deposited human or murine cDNAs. The simulation approach and experimental protocol proposed here permit the efficient isolation of coding cDNA fragments from differentially expressed genes.

AVAILABILITY

Freely available on request from the authors.

CONTACT

fesce.riccardo@hsr.it

Control of hypertension in Italy: results of the "Study on Antihypertensive Treatment in General Practice (STAP)". Physicians Taking Part in STAP

BACKGROUND

Various epidemiological surveys from different countries have documented the unsatisfactory control of arterial hypertension. The aim of this study was to assess the current status of treatment and control of hypertension in Italy.

METHODS

A random sample of general practitioners (GP) working in several Aziende Sanitarie Locali (Local health offices-ASL) throughout Italy were invited to take part in the study. Each doctor had to recruit a random sample of 15-20 hypertensive patients receiving antihypertensive drugs among those attending his/her office for any reason. A standard medical history, specifically oriented to hypertension and its pharmacological treatment, was taken for each patient. Three blood pressure (BP) measurements were made, with the patient seated for at least 5 minutes, using an accurate automatic device (A&D UA-732), and the mean was taken as each patient's BP.

RESULTS

A total of 73 GPs (17% of the invited sample), working in 14 Italian ASL (six in the north of the country, four in the center and four in the south and islands), agreed to participate in the study. They recruited an average of 17 patients each, for a total of 1204 hypertensive subjects (663 women and 541 men) 633 of whom were 65 years old or more, mean age 64 +/- 11 years, range 25-94 years. More than half (56%) had been taking antihypertensive drugs for at least five years; 42% were taking one drug, 40% two, 16% three and 2% four drugs. Respectively, 63% and 23% had systolic BP (SBP) > or = 140 and > or = 160 mmHg; 28% and 14% had diastolic BP (DBP) > or = 90 and 95 mmHg. In 71%, BP was < 160/95 mmHg, but only 33% had BP lower than 140/90 mmHg. BP control was similar in males and females, but worse in the elderly. Nine percent of patients complained of symptomatic side effects, usually mild. Only 8% admitted to poor compliance with the antihypertensive therapy, and their BP was significantly less well controlled.

CONCLUSIONS

Control of BP in patients receiving antihypertensive drugs is still far from optimal in Italy, just as in other countries. This situation seems more related to the fact that doctors do not tackle the problem aggressively, than to the patients' degree of compliance with therapy.

Long-term effects of angiotensin-converting enzyme inhibitors and calcium antagonists on the right and left ventricles in essential hypertension

To compare the effects of chronic antihypertensive treatment on left and right ventricular structure and function, 24 patients with mild to moderate, never-treated hypertension were randomized to receive fosinopril (20 mg daily) or amlodipine (10 mg daily) for 12 months. At baseline and subsequently at the end of third, sixth, and twelfth months, each patient underwent an integrated echocardiographic study and noninvasive ambulatory blood pressure monitoring. Both drugs significantly reduced blood pressure, casual or monitored (p < 0.01), and left ventricular mass index (from 125 +/- 32 to 100 +/- 12 gm/m2 [p < 0.02] with amlodipine and from 106 +/- 18 to 89 +/- 10 gm/m2 [p < 0.02] with fosinopril). The decrease in left ventricular mass was essentially caused by a reduction of ventricular thickness. Free right ventricular wall thickness was also lowered in both groups, more consistently with amlodipine (from 8.0 +/- 2.1 to 6.4 +/- 0.8 mm; p < 0.01), without an increase in plasma natriuretic peptide and insulin concentrations or heart rate. With both treatments, the decrease in ventricular mass was not associated with impairment of systolic function, whereas a trend toward an improvement of Doppler echocardiographic indexes of biventricular diastolic function was observed. In conclusion, both amlodipine and fosinopril induced similar qualitative effects on anatomy and function of both ventricles. The clinical meaning of these observations must be defined further by means of adequately sized prospective trials.

Albuminuria and transferrinuria in essential hypertension. Effects of antihypertensive therapy

The objectives of this study were to evaluate the effects of an ACE inhibitor (fosinopril) and a calcium antagonist (amlodipine) on the urinary albumin and transferrin excretion and their relationship to the blood pressure in essential hypertension. Twenty-four never-treated patients (mean age, 46.4 +/- 8.9 years) with a diastolic blood pressure between 90 and 114 mm Hg and normal renal function, randomly received amlodipine or fosinopril and, if the diastolic blood pressure was not normalized, doxazosin was added to the therapy. Twenty-four-hour ambulatory blood pressure monitoring and 24-h urine collection for albumin and transferrin measurements were performed before and after 3 and 6 months of therapy. Diastolic blood pressure was normalized in 23 patients (96%). Before treatment, microalbuminuria was present in 50% of patients. In the amlodipine and fosinopril group, antihypertensive therapy significantly decreased blood pressure and, only in the fosinopril group, albuminuria. Transferrinuria did not change significantly in both groups. Fosinopril lowered albuminuria in all patients, whereas amlodipine only in half of patients. Albuminuria, but not transferrinuria, was significantly correlated to the ambulatory blood pressure. This correlation was more pronounced for systolic than for diastolic pressure. In essential hypertensive patients with normal renal function, a high prevalence of microalbuminuria can be observed. Albuminuria appears to correlate with ambulatory blood pressure, particularly with systolic pressure. Intrarenal hemodynamic changes seem to play a more important role than systemic blood pressure decrease in the reduction of albuminuria. Transferrinuria does not seem a useful marker to follow-up nondiabetic hypertensive patients with early signs of glomerular dysfunction.

How informed general practitioners manage mild hypertension: a survey of readers of drug bulletins in 7 countries. International Society of Drug Bulletins (ISDB)

OBJECTIVE

To determine whether general practitioners (GP) who are readers of independent drug bulletins can be used as an international epidemiological observatory of the criteria adopted by "well informed" doctors in various countries in the management of mild hypertension.

DESIGN

Questionnaire study of GPs' diagnostic criteria for mild hypertension, routine investigation and management of patients with this diagnosis.

PARTICIPANTS

206 GPs readers of independent drug bulletins in 7 countries, comprising 95 known systematic readers of a local bulletin and 111 randomly selected regular subscribers.

MAIN OUTCOME MEASURES

Response rate to the questionnaire. Diagnostic criteria, routine investigations, and treatment used for patients with mild hypertension.

RESULTS

The study required two months for planning and implementation. Four countries out of eleven had a response rate < or = 50% and were excluded; the frequency of responses from other countries was 69%. The average diastolic blood pressure (DBP) considered diagnostic of mild hypertension range from 94 mm Hg (lower threshold) to 106 (upper threshold). A minority (17%) of GPs routinely request the minimum recommended laboratory tests to assess patients. GPs routinely advise non-drug measures before starting a drug. Most would not start drug treatment in patients without other risk factors and a DBP below 100 mmHg. The top first choice drugs were diuretics and beta-adrenoceptor blockers. Half of the doctors were able to quote some published guide to the management of mild hypertension, and 18% cited a relevant trial. Attitudes in diagnosing and treating mild hypertension differed widely between GPs and countries.

CONCLUSIONS

GP readers of drug bulletins can be used quickly and inexpensively to assess the extent to which recommended diagnostic and therapeutic practices are accepted by "well informed" doctors. The results suggest that attitudes in managing mild hypertension vary widely among GPs and countries and differ remarkably from the recommendations of published guidelines.

Antihypertensive efficacy and tolerability of different drug regimens in isolated systolic hypertension in the elderly

The pharmacological treatment, mainly based on diuretics, of isolated systolic hypertension (ISH) has recently been shown to reduce the risk of stroke and coronary heart disease in the elderly. The purpose of this study was to compare the antihypertensive effect and tolerability of different drug regimens in elderly subjects with ISH (systolic blood pressure--SBP-- > or = 160 mmHg and diastolic blood pressure--DBP-- < 90 mmHg). A multicentre, randomized, controlled open trial was planned in the general practice setting. Four widely used treatment schedules were tested: hydrochlorothiazide 25 mg plus amiloride 2.5 mg (H+Am), nifedipine slow release 20 mg (N), atenolol 50 mg (At) and atenolol 25 mg plus chlorthalidone 6.25 mg (At+C). After a baseline evaluation, 308 patients (76.3% female, mean age 75.3 +/- 7.1 years) were randomized and followed up for 6 months. After 3 months the drug dosage was doubled if the systolic blood pressure goal (SBP < 160 mmHg and SBP reduction of at least 20 mmHg) had not been reached. Ninety-four subjects (30.5%) presented contraindications to beta-blockers. At the 3rd- and 6th-month visits all treatment groups, except At, showed a significant reduction in SBP compared to the control group; DBP showed no significant reduction in any group at any time. At the end of the follow-up the percentage of hypertensives who had reached the BP goal was 14.6% in the control group, 52.9% in H+Am, 54.8% in N, 28.6% in At and 52.2% in At+C.(ABSTRACT TRUNCATED AT 250 WORDS)

Feasibility of a long-term low-sodium diet in mild hypertension

The present study set out to assess the feasibility of long-term moderate dietary sodium restriction in patients with mild hypertension in general practice. After screening and a run-in phase of 6-8 weeks, a total of 77 previously undiagnosed mildly hypertensive patients were identified. Half of them were randomized to receive a few simple dietary instructions from their general practitioners in order to reduce salt usage; the others were randomized to receive no advice. The patients were followed up for 12 months with quarterly visits. A total of 56 patients (72.7%) completed the study, 26 on a low-sodium diet (LD) and 30 on their usual diet (UD). At each visit in the diet phase, patients provided 24h urine, which was analysed for volume and sodium concentration in order to assess their sodium intake. Blood pressure, heart the rate and body weight were recorded. The mean urinary sodium excretion for all diet phase visits overlapped in the two groups (177.0 +/- 32.9 vs. 169.3 +/- 49.4 mEq/24h respectively in the LD and UD groups). Nevertheless the mean systolic and diastolic blood pressures for all diet phase visits were significantly lower in the LD than in UD group (144.2 +/- 11.1/91.6 +/- 6.4 and 148.0 +/- 13.7/95.6 +/- 4.7 mmHg respectively, P less than 0.01). Our data suggest that it is not feasible at present to reduce sodium intake in mild hypertensives with simple and inexpensive dietary instructions, the only ones suitable for widespread application in general practice.

Prevalence and variability of orthostatic hypotension in the elderly. Results of the 'Italian study on blood pressure in the elderly (SPAA)'. The 'Gruppo di Studio Sulla Pressione Arteriosa nell'Anziano'

The prevalence of orthostatic hypotension (OH) in an elderly outpatient population was assessed according to the most common criteria given in the literature. Short-term OH variability and relationships between OH and its known risk factors were also analysed. A sample of 3858 elderly outpatients aged 65 years or more was randomly recruited by 444 Italian general practitioners. The patients' blood pressure (BP) and heart rate were recorded in both lying and standing positions at two visits 7 days apart. Three definitions were used for the identification of OH: (1) a decrease in systolic BP greater than 20 mmHg (SOH); (2) a decrease in both systolic (greater than 20 mmHg) and diastolic (greater than 10 mmHg) BP (SDOH); (3) any decrease in systolic BP associated with symptoms (SyOH). Prevalence figures for SOH were 13.8% at the first and 12.6% at the second visit, and respectively 5.3 and 4.8% for SDOH, 14.1 and 11.8% for SyOH. All the criteria were met by less than 2% of subjects at each visit. The diagnosis of OH was confirmed at both visits in 36.3% of cases for SOH, in 25.7% for SDOH, and in 43.9% for SyOH. Each different OH definition identifies a population subgroup characterized by different sets of risk-factors. The presence and prevalence of OH is difficult to define because different people may be identified by the currently accepted criteria or by the same criterion over a short time.

Effects of long-term treatment with prazosin on left ventricular diastolic function in mild to moderate hypertension

It is not well established if blood pressure control is associated with an improvement in diastolic function, whose impairment represents an early marker of cardiac involvement in systemic hypertension. The purpose of this study was to evaluate whether a prolonged treatment with an alpha 1-blocking agent can lead to a reversal of the abnormalities of left ventricular filling. Eleven never-treated patients with mild to moderate essential hypertension were examined before and after at least six months of treatment with prazosin. Cardiac function and left ventricular mass were measured by means of radionuclide ventriculography and echocardiography. Average blood pressure values significantly decreased during the treatment period: from 163.54 +/- 17.80 mm Hg to 146.81 +/- 13.14 mm Hg for systolic blood pressure and from 106.09 +/- 6.96 mm Hg to 92.90 +/- 8.93 mm Hg for diastolic blood pressure. All the indices of left ventricular mass showed a trend toward reduction, but the differences with respect to the baseline values did not reach statistical significance. Average value of ejection fraction was normal before treatment and did not change significantly after treatment. All indices of diastolic function were significantly lower than normal controls' values at the beginning of the study and tended to worsen at the end of the study. Our findings suggest that diastolic function is not consistently affected by the therapy with alpha 1-adrenoreceptor antagonists despite good blood pressure control.

Left ventricular diastolic function in normotensive adolescents with different genetic risk of hypertension

Abnormalities of the diastolic function of the left ventricle are the first sign of cardiac involvement in arterial hypertension. We have studied the diastolic function in a group of normotensive adolescents with confirmed family history of hypertension. M-mode echocardiography was performed in 86 normotensive males aged 14-19 years: 41 sons of at least one hypertensive parent (SHT) and 45 sons of normotensive parents (SNT). Cross-sectional area of the left ventricle and left ventricular (LV) mass index were significantly greater in the SHT than in the SNT group (10.05 +/- 1.84 vs. 8.9 +/- 1.56 cm/m2, p less than 0.01 and 129.3 +/- 296.3 vs. 109.23 +/- 25.7 g/m2, p less than 0.002, respectively). No significant difference between the two groups was observed in the indices of left ventricular diastolic function, except for mitral valve opening rate (463.51 +/- 90.45 in SHT vs. 416.71 +/- 78.84 mm/s in SNT; p less than 0.02). From the analysis of the subgroup of adolescents having left ventricular mass greater than the upper normal value, we observed that they showed mean time of rapid filling significantly longer than SNT: this could represent an early marker of the pathological character of such hypertrophy. Our results suggest that the higher LV mass observed in the SHT is not associated with chamber and myocardial stiffness abnormalities.

[Isolated systolic hypertension in the elderly]

Isolated systolic hypertension (ISH) is a very common condition in the elderly, even more than diastolic hypertension. Several studies indicate that ISH is a considerable cardiovascular risk factor in the elderly but the benefit of antihypertensive treatment has not been proved. Data in the literature on prevalence, pathophysiology, prognostic meaning and treatment of ISH are critically reviewed.

Antihypertensive treatment of the elderly in general practice

In order to assess the antihypertensive care received by the elderly, where clear therapeutic guidelines are lacking, a population of 3,858 aged over 64 years was studied. Data were derived from a large Italian 'Study on Blood Pressure in the Elderly', carried out in general practice. Over 90% of the 2,059 known hypertensive patients were receiving drug treatment, with no age or sex-related differences. A single drug was prescribed to 50.2% of treated patients; only 5.5% were receiving three or more drugs. Diuretics and older sympatholytic agents were by far the most frequently prescribed categories, with four drugs (hydrochlorothiazide, amiloride, methyldopa and chlorthalidone) accounting for over 50% of all prescriptions. Low-dosage treatment schedules were frequently used, often associated with less-often-than-daily drug administration. Our study shows that physicians' attitudes to the treatment of arterial hypertension in the elderly are fairly uniform, with treatment of all subjects but with low drug dosages.

Awareness, treatment, and control of hypertension in the elderly in a general practice experience. Study Group on Hypertension in the Elderly

In 3858 ambulatory elderly people (age greater than or equal to 65 years) prevalence of hypertension was 67.8%. The hypertensive status was unknown to both the doctor and the patient in 21.4% of cases. More than 90% of known hypertensives were treated, but hypertension could be considered as controlled in less than 30% of them.

[Relations between pressure overload and early signs of cardiac involvement in arterial hypertension]

In arterial hypertension the indexes of left ventricular hypertrophy are not related to resting blood pressure, whereas a positive association with exercise blood pressure has been observed. It has not been investigated a possible relationship between response to stress and left ventricular diastolic function, the latter being early involved in arterial hypertension even before the development of ventricular hypertrophy. The present study was aimed at assessing a possible relationship between blood pressure response to dynamic exercise and index of left ventricular mass, systolic and diastolic function in a group of untreated hypertensives. fourty hypertensives aged 16-56 years were studied, 27 with mild hypertension and 13 with moderate or severe hypertension. The control group consisted of 23 normotensive healthy subjects, aged 14-40 years. All the subjects underwent a maximum-graded bicycle exercise in the supine position and a M-mode echocardiogram under the B-mode drive. Average values of the indexes of ventricular hypertrophy and of systolic function were overlapping in the 3 groups. Significant differences were observed in the indexes of diastolic function; with regard to normatensive controls, hypertensive subjects showed an increase in isovolumic relaxation time and rapid filling time, a decrease of isovolumic and rapid filling rates and a reduction of mitral valve closing and opening velocities.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of symptoms generally attributed to hypertension or its treatment: study on blood pressure in elderly outpatients (SPAA)

A number of symptoms that appear to be associated with high blood pressure (headache, dizziness, epistaxis, tinnitus, weakness, drowsiness), and are usually regarded as secondary to hypertension or to antihypertensive drug therapy, were studied in 3858 elderly patients, 67.8% of whom were hypertensive. Of the hypertensive patients, 71.2% were under treatment. Headaches and dizziness were significantly more prevalent in the hypertensive than in the normotensive subjects (32.5 versus 27.4% and 41.5 versus 35.3%, respectively; P less than 0.05) and in treated compared with untreated hypertensives (33.3 versus 29.4% and 43.3 versus 37.1%; P less than 0.05). These differences disappeared after statistical correction for 'awareness of hypertension'. In multiple logistic analysis, female sex, age and awareness of hypertension were significantly associated with a higher prevalence of symptoms, whereas hypertension and antihypertensive treatment were not. We conclude that the presence of these symptoms does not constitute a reliable criterion for starting antihypertensive treatment or judging its efficacy.

Assessment of ventricular function in arterial hypertension with radionuclide ventriculography

Diastolic function of the left ventricle was assessed in 29 untreated patients with mild to moderate hypertension and in 21 normotensive control subjects using gated radionuclide ventriculography. In hypertensive patients, the time to peak filling rate was significantly longer (p less than 0.01) than that in control subjects, and first-third filling fraction and peak filling rate were significantly reduced (p less than 0.001). The ejection fraction and peak ejection rate were also significantly reduced in hypertensive patients (p less than 0.001). No relation was observed between diastolic functional impairment and age, cardiac hypertrophy, or severity of hypertension. Thus, early impairment of ventricular filling is present in hypertension, even in young patients without evidence of cardiac hypertrophy.

Arm position as a source of error in blood pressure measurement

The present study was designed to assess the value of correct positioning of a patient's arm when measuring blood pressure (BP). A total of 181 subjects were examined, 141 hypertensives on treatment, 25 untreated hypertensives, 15 normotensives. All the subjects underwent three BP measurements after a 5-min resting period in supine position. Then two BP readings were recorded in standing position with the arm either positioned by the patient's side or supported passively at patient's heart level. Average systolic BP (SBP) in standing position were 144.6 +/- 20.2 mmHg with the arm at the side and 136.4 +/- 21.1 mmHg with the arm at the heart level (p less than 0.001); average diastolic pressures were 99.0 +/- 12.0 mmHg and 90.2 +/- 12.3 mmHg (p less than 0.001), respectively. A fall in SBP greater than or equal to 20 mmHg from the supine to the upright position was detected in 18.2% of cases when measurement was performed at heart level; such a reduction was inapparent in two-thirds of cases when the arm was placed at the patient's body side. Incorrect positioning of a patient's arm during BP measurements in standing position leads to overestimation of BP values and masks the presence of postural hypotension.

[Usefulness of exertion tests in the evaluation of the effectiveness of antihypertensive therapy]

Aim of this study was to assess the reliability of blood pressure (BP) response to exercise compared with the occasional BP measurements in evaluating the efficacy of an antihypertensive therapy. We have studied 40 subjects (22 M, 18 F mean age 33.3 +/- 6.6) with essential hypertension (19 with mild hypertension, 8 with moderate hypertension, 13 with severe hypertension). Every patient underwent a maximum graded exercise test in the supine position on a bicycle ergometer before starting the antihypertensive treatment. An exercise test was repeated with the same procedure after resting BP had been normalized for at least six months. Both systolic and diastolic BP at peak exercise were significantly reduced (systolic BP from 212.13 +/- 25.79 mmHg to 194.38 +/- 21.58 mmHg; diastolic BP from 128.00 +/- 16.52 to 114.1 +/- 11.02 mmHg) during the second test. An excessive BP increase (above the 95% confidence limits of the BP response to exercise in a group of normotensives) was observed in 32 subjects during the first test. A "hypertensive" response to stress persisted in 13 subjects during the second test even if the resting BP values were normalized. Our data support the value of stress testing in both the evaluation of the hypertensive patient and the assessment of the individual response to treatment.

Feasibility of a large prospective study in general practice: an Italian experience. Gruppo di Studio sulla Pressione Arteriosa nell'Anziano

A study of blood pressure control in elderly outpatients was carried out with the participation of 444 Italian general practitioners. Of 4096 patients aged 65 years or over who were considered for recruitment, 3959 (96.7%) fulfilled all the criteria of admission and were followed up for 12 months. The findings regarding one of the aims of the study--that is, to assess the feasibility of a large scale trial in general practice--are reported. Most (87%) of the doctors completed the study. Their adherence to the protocol was highly satisfactory, leading to an acceptable quality of work. Patients' compliance was also good; 98.6% (3898) of the patients who had fulfilled the admission criteria agreed to participate in the study, and only 4% (158) dropped out. Both of these observations support the feasibility of carrying out prospective studies in general practice. The creation of networks of general practitioners who are prepared to carry out research in their practices would allow treatment and preventive measures to be studied simply and at low cost in the appropriate setting.

Left ventricular structure and function in normotensive adolescents with a genetic predisposition to hypertension

It has been suggested that the heart plays an active role in the pathogenesis of arterial hypertension. If this is true, there must be early cardiac involvement in young normotensive subjects who develop hypertension later in life and differences in cardiac morphology or function may exist between young normotensive subjects with different risks of developing hypertension. M-mode echocardiography was performed in 51 normotensive male adolescents with at least one hypertensive parent (SHT). These subjects were compared with 55 normotensive sons of normotensive parents (SNT) and with 25 adolescents with borderline hypertension (BH). Control groups were matched for sex and age. The following morphologic parameters were significantly greater in the SHT group than in the SNT group: interventricular septum (0.54 +/- 0.08 vs 0.49 +/- 0.09 cm/m2; p less than 0.01) and posterior wall (0.54 +/- 0.11 vs 0.50 +/- 0.08 cm/m2; p less than 0.05) thickness, left ventricular mass (125.0 +/- 29.1 vs 109.2 +/- 25.4 gm/m2; p less than 0.005), and cross-sectional area (9.9 +/- 1.8 vs 8.9 +/- 1.6 cm2/m2; p less than 0.005). No significant differences between SHT and BH subjects were observed. Excursion of left ventricular posterior wall was significantly higher in the BH group. No differences were observed between SHT and SNT subjects. These data show that the same kinds of changes in cardiac morphology are present in normotensive subjects with a family history of hypertension and in subjects with borderline hypertension, suggesting that cardiac involvement may precede elevation of blood pressure.

[Echocardiographic evaluation of the left ventricular morphology and function in adolescents with mild arterial hypertension]

A few studies have been carried out in humans on the morphology and function of the cardiovascular system in the early phases of hypertension. Furthermore, the data which have been provided are controversal and, in particular, a hyperkinetic status has been found only by some authors. For this reason, we planned to study the type and degree of cardiac involvement in 25 male adolescents with mild hypertension, by means of M-mode echocardiography. The control group consisted of 100 normotensive males matched for age and sex. The following indices of left ventricular hypertrophy were significantly higher in cases than in controls: posterior wall thickness (10.4 +/- 1.0 vs 9.1 +/- 1.7 mm; p less than 0.001), cross sectional area (18.3 +/- 2.7 vs 16.6 +/- 3.2 cm2; p less than 0.02) and left ventricular mass (230.9 +/- 46.7 vs 206.2 +/- 54.0 g; p less than 0.05). After normalizing for body surface area, only posterior wall thickness was still significantly greater in cases (5.7 +/- 0.6 vs 5.2 +/- 1.0 mm/m2; p less than 0.01). Among the indices of left ventricular function, only the posterior wall excursion was significantly greater in mild hypertensives than in controls. Our data do not confirm the existence of a hyperkinetic status in subjects with mild hypertension. The type of morphological alterations we found and their modest correlation to blood pressure suggest that factors besides an increased afterload are involved in the development of left ventricular hypertrophy.

Role of blood pressure response to provocative tests in the prediction of hypertension in adolescents

To assess the value of exercise stress testing and of mental stress as predictors of hypertension, we studied 130 normotensive males 14-18 years of age. Sixty-five had at least one hypertensive parent (SHT), while 65 had normotensive parents (SNT). Systolic (SBP) and diastolic (DBP) blood pressure, rate-pressure product (RPP) and 12-lead ECG were recorded at rest, throughout the tests and during the recovery phase. The two groups were not significantly different at rest for the examined variables. However, the SHT group showed a greater average SBP than the SNT group (198.4 +/- 18.7 vs 189.5 +/- 14.9 mmHg; P less than 0.05) at the peak of exercise. A significantly higher proportion of SHT subjects (40.0% vs 18.5%: P less than 0.01) had SBP greater than 200 mmHg. No difference in the ECG pattern between the two groups was observed. During mental stress, no significant differences in the examined variables between the two groups were noted, although SBP, DBP, HR and RPP were slightly higher in SHT than in SNT subjects. These data suggest that the SBP response to dynamic exercise may be a good predictor of hypertension in subjects at risk.

Long-term efficacy of screening for hypertension in a community

Screening for hypertension in the community leads to the identification of hypertensive people not previously detected, and those detected but inadequately treated or not treated at all. The aim of the present study was to assess the long-term efficacy of screening for blood pressure control in a general population. During 1981, 2139 parents of high school students were invited to our institute for a blood pressure measurement; 1533 persons (71.7%) attended the screening; 239 of them (15.6%) were found to be hypertensive (diastolic blood pressure greater than or equal to 95 mmHg or already receiving antihypertensive treatment). Among the hypertensives, 42.3% did not know that they had high blood pressure, and only 7.5% had their blood pressure controlled by treatment. After being informed about the importance of lowering their blood pressure levels, all hypertensives were invited again to the institute for a further evaluation. Two hundred and two persons (84.5%) attended the re-examination. Of these, 154 (76.2%) were still hypertensive. Of the 202, 151 (74.7%) had contacted their physicians. The most common advice was to make further measurements of blood pressure over a period of time, followed by laboratory tests. The proportion of treated hypertensives rose from the initial 33.1% to 53.9%, but in about half the patients normalization of blood pressure was not achieved. Physicians tended to treat only people with moderate to severe hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

[Index of left ventricular hypertrophy in adolescents genetically predisposed to the development of arterial hypertension]

Experimental studies on strains of normotensive rats genetically prone to hypertension and investigations on humans with borderline hypertension have shown an early involvement of the heart, mainly consisting in a trend to ventricular hypertrophy. To assess whether such alterations may preceed or follow the elevation of blood pressure, subjects who will develop hypertension, but whose blood pressure is currently normal must be studied. For this reason, we studied by means of M-mode echocardiography 51 normotensive males aged 14-19 years with family history for hypertension (at least one hypertensive parent; SHT). Fifty-five normotensive subjects with both normotensive parents (SNT), matched for sex and age, were the controls. Average values of the following parameters were significantly higher in SHT than in SNT subjects: interventricular septum (5.4 +/- 0.8 versus 4.9 +/- 0.9 mm/m2; p less than 0.01) and posterior wall (5.4 +/- 1.1 versus 5.0 +/- 0.8 mm/m2; p less than 0.05) thickness, left ventricular mass (125.0 +/- 29.1 versus 109.2 +/- 25.4 g/m2; p less than 0.005) and cross sectional area (10.0 +/- 1.8 versus 8.9 +/- 1.6 cm2/m2; p less than 0.005). No significant difference between the two groups was observed in the indexes of left ventricular function. The existence of alterations of cardiac morphology in normotensive adolescents with genetic risk of hypertension shows that the cardiac involvement may preceed the development of high blood pressure.

[Association between arterial pressure and other cardiovascular risk factors in adolescence]

A screening for hypertension and other cardiovascular risk factors was carried out during 1981 in a population of 1142 subjects (675 males and 467 females) aged 14-18 years. Aim of the study was to analyze the distribution of blood pressure values and of variables possibly associated with hypertension in a population of adolescents. The mean value of systolic blood pressure was higher in males than in females, slightly increasing with age in males and decreasing in females. The diastolic blood pressure was similar, and increased with age in both sexes. The prevalence of individuals with systolic blood pressure greater than or equal to 140 mmHg resulted of 16.1% in males and of 5.6% in females; the prevalence of adolescents with diastolic blood pressure greater than or equal to 90 mmHg was much lower, being of 2.5% and 1.5% respectively. The average value of heart rate was higher in females and decreased with age in both sexes. Males showed significantly greater height and weight, but the body mass index was nearly equal in the two sexes; females had thicker skinfolds. All these variables only in males were clearly associated with age. Among anamnestic variables, only smoking habits, alcohol consumption and physical activity were significantly different in the two sexes. A positive family history for hypertension was present in 31.4% of the adolescents in whom an objective assessment was possible. In both sexes the systolic blood pressure appeared significantly related to heart rate, body weight, body mass index and skinfold thickness.(ABSTRACT TRUNCATED AT 250 WORDS)