The deletion/insertion polymorphism of the angiotensin converting enzyme gene and cardiovascular-renal risk

OBJECTIVE

This meta-analysis attempted to derive pooled estimates for the associations between various cardiovascular-renal disorders and the deletion/insertion (D/I) polymorphism of the angiotensin converting enzyme (ACE) gene.

METHODS

Case-control studies were combined, using the Mantel-Haenszel approach. Joint P values for continuous variables were calculated by Stouffer's method. Continuous measurements reported in different units were expressed on a percentage scale using the within-study mean of the II genotype as the denominator.

RESULTS

The computerized database used for this analysis included 145 reports with an overall sample size of 49 959 subjects. Overall, possession of the D allele was associated with an increased risk of atherosclerotic and renal microvascular complications. In comparison with the II reference group, the excess risk in DD homozygotes (P < 0.001) was 32% for coronary heart disease (CHD; 30 studies), 45% for myocardial infarction (20 studies), 94% for stroke (five studies) and 56% for diabetic nephropathy (11 studies). The corresponding risk in DI heterozygotes amounted to 11% (P= 0.02), 13% (P= 0.02), 22% (P= 0.10) and 40% (P < 0.001), respectively. Hypertension (23 studies), left ventricular hypertrophy (five studies), hypertrophic or dilated cardiomyopathy (eight studies) and diabetic retinopathy (two studies) were not related to the DI polymorphism. Publication bias was observed for CHD, myocardial infarction and microvascular nephropathy, but not hypertension. In studies with DNA amplification in the presence of insertion-specific primers, the risk associated with the DD genotype increased to 150% [95% confidence interval (CI) 76-256; four studies] for diabetic nephropathy, but decreased to 12% (95% CI -3 to 28; seven studies) for CHD and 14% (95% CI -6 to 37; four studies) for myocardial infarction. On the other hand, the pooled odds ratios did not materially change if the meta-analysis was limited to articles published in journals with an impact factor of at least 4. Furthermore, compared with the II control group, the circulating ACE levels (29 studies) were raised 58 and 31% (P < 0.001) in DD and DI subjects, respectively. In contrast, plasma renin (10 studies), systolic and diastolic blood pressure (46 studies) and body mass index (30 studies) were not associated with the D allele.

CONCLUSION

The D allele is not associated with hypertension, but behaves as a marker of atherosclerotic cardiovascular complications and diabetic nephropathy. These associations do not necessarily imply a causal relationship and may have been inflated by publication bias. Nevertheless, their possible therapeutic implications may be subject to further investigation in prospective (intervention) studies.

Unexpected effects of coffee consumption on liver enzymes

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

Conventional and ambulatory blood pressure and menopause in a prospective population study

Whether menopause would be associated with a rise in blood pressure (BP) was prospectively assessed in a cohort study. A total of 315 women (30-70 years at follow-up) were randomly selected from the population. They were matched on age and rank of body mass index with 315 men. Five BP readings were obtained by conventional sphygmomanometry (CBP) at the subjects' homes on each of two baseline visits and at one follow-up visit. The 24-h ambulatory BP was recorded at follow-up. Menstrual status was assessed by questionnaire. The statistical tests were two-sided and accounted for age, body mass index, antihypertensive treatment, contraceptive pill intake or changes in these variables. From baseline to follow-up (median, 5.2 years), 166 and 105 women stayed pre- or postmenopausal, while menses ceased in 44 perimenopausal women. In cross-sectional analyses, the postmenopausal women, compared with their pre- and perimenopausal counterparts, had a 4-5 mm Hg higher systolic CBP (15 readings per subject) and 24-h BP (P < or = 0.05 for differences between peri- and postmenopausal women). Furthermore, systolic CBP rose nearly 5 mm Hg per decade more (P < or = 0.05) in peri- and postmenopausal women than in premenopausal subjects. In addition, the longitudinal results showed that systolic CBP did not change in women who stayed premenopausal throughout follow-up (P=0.71), but increased by approximately 4 mm Hg over 5 years in peri- (P=0.07) and postmenopausal (P= 0.01) subjects (P=0.02 for difference between pre-and postmenopausal women). Such trends were not observed for diastolic BP in women or for systolic and diastolic BP in men. In conclusion, menopause per se may potentiate the age-related increase in systolic pressure. Because confined to systolic pressure, this specific effect of menopause may be mediated via a reduction in arterial compliance.

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

OBJECTIVE

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

DESIGN

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

SETTING

The University of Padova, Department of Internal Medicine.

SUBJECTS

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

INTERVENTIONS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

Ossification timing of sacral vertebrae by ultrasound in the mid-second trimester of pregnancy

OBJECTIVES

The aim of the study was to establish the ossification timing of sacral vertebrae by ultrasonography in the second trimester of pregnancy, for the diagnosis of caudal regression syndrome with isolated sacral agenesis.

METHODS

The study was carried out on 77 normal single pregnancies, at gestational ages ranging from 15 to 21 weeks, using high-resolution transabdominal echography. The sacral region was visualized in a coronal plane, when the fetus was in anterodorsal position. The level of ossification of sacral vertebrae (S1 to S5) at each gestational age was recorded. Each sacral region was examined three times by the same observer and the nucleus was considered as present when it was visualized at least two times out of three. Blind assessment was performed three times by a second observer, who was not present at the previous examination, for interobserver and intraobserver error analysis.

RESULTS

Interobserver and intraobserver error calculation demonstrated the reproducibility of the method. Concordance between the two observers as evaluated by Cohen Kappa index was 0.77 (C.I. 95%, 0.69-0.85).S1 ossification nuclei were visualized in all fetuses at 15 weeks and S2 nucleus was found in all fetuses within 17 weeks. S3 nucleus was detected in 45% of fetuses by the beginning of the 16th week. S4 was visualized in 55% of the cases at 18 weeks and progressively in a higher percentage of cases during the following weeks of gestation.

CONCLUSION

The data obtained showed that the sequence of development of sacral region ossification was related to gestational age. This observation allows clinicians to accurately exclude isolated sacral agenesis at 16 to 17 weeks of gestation, when the S1-S2 ossification nuclei are visualized. This opportunity may be of particular value in the offspring of diabetic mothers.

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

OBJECTIVE

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

DESIGN

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

PARTICIPANTS

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

RESULTS

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

CONCLUSIONS

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

Fetal spine ossification: the gender and individual differences illustrated by ultrasonography

The spatial and temporal pattern of manifestation of ossification nuclei of the spinal column in fetal life have been well established by histologic and radiologic studies. Sonographic evaluation of the fetal spine depends on visualization of the ossification centers, but the sequence of development of ossification centers in the vertebral column obtained by embryologists and sonographers and radiology are conflicting. We carried out a longitudinal study to establish the ultrasonographic appearance and timing of development of primary ossification centers of the fetal spine in the first and second trimesters of pregnancy. A total of 80 mothers were evaluated during their pregnancy with two echographic controls; in the first trimester, the spine length was measured and, in the second trimester of pregnancy, the timing of ossification of the bodies and neural arches of sacral vertebrae and the difference in appearance between the female and male genders were evaluated. Spinal length measurements obtained in the first trimester and percentage of detection of sacral vertebral structures increased progressively with a regular pattern in relation to gestational age. Spinal length at first ultrasound examination was slightly correlated with time of appearance of sacral bodies and arches. Ossification timing was significantly earlier in females than in males. The study has attempted to improve our understanding of the sonographic detection of the spinal ossification. Data presented give some further information on the stages of appearance of sacral vertebrae body centers during intrauterine development. Differences between genders and interindividual variations in ossification timing were observed at a very early stage of development. This could be of value when fetal growth is evaluated. Moreover, further knowledge of spinal development may be useful for early diagnosis of spinal abnormalities and for fetal biometrics.

Blood pressure and metabolic profile after surgical menopause: comparison with fertile and naturally-menopausal women

In 1978 a random sample (367 men and 568 women aged 18-65 years) taken from the general population of a north-eastern Italian town was screened for cardiovascular risk; 16 years later, the women were invited to a second screening. Three groups were identified at the initial screening (fertile, naturally menopausal and surgically menopausal) and four in the longitudinal study (137 remained fertile during the whole study, 205 became naturally menopausal, 56 were ovariectomised and 127 were already going through the menopause). The protocol included a questionnaire, blood pressure (BP) measurement, and blood exams. Continuous variables were adjusted for confounders. Systolic BP, prevalence of hypertension, cholesterol, glycaemia and uricaemia were similar, whereas diastolic and triglycerides (TG) were lower in surgically-menopausal than in fertile women (P < 0.001). No significant difference in 16 years' variation from baseline was observed between the four groups, although women who remained fertile showed the smallest increases. In particular, neither systolic or diastolic BP increases differed between the women who were oophorectimised and those who remained fertile. 'Fertile status' was rejected from the logistic equation of incidence of hypertension, and 'age of menopause' was also rejected when this analysis was repeated in ovariectomised women. New coronary artery disease (angina pectoris or myocardial infarction) was observed in one ovariectomised woman, in three naturally menopausal, and in 13 already menopausal women which seemed to reflect the age trend. No new cases were observed in women who remained fertile. In conclusion, in Italian women surgical menopause, similarly to natural menopause, is devoid of any negative prognostic effect. Journal of Human Hypertension (2000) 14, 799-805

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

AIM

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

PATIENTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hemodynamics following real and hypnosis-simulated phlebotomy

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

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

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

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

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

Spine length measurement in the first trimester of pregnancy

OBJECTIVES

The aim of the study was to evaluate spine length as an indicator of skeletal growth in the first trimester of pregnancy and to provide a nomogram of spine length at the end of the first trimester of pregnancy.

METHODS

The study was carried out on 420 single pregnancies, at gestational ages ranging from 11 to 14 weeks, using high-resolution transabdominal echography. Biparietal diameter and crown-rump length (CRL) were measured to date the pregnancy. Using the same scanning plane used to measure CRL, the whole spine length in antero-dorsal position can be visualized as a double hyperechoic line from 10 weeks of gestation onwards. Spine length was measured three times by one observer and the mean of the three measurements was considered as definitive. Forty fetuses had multiple measurements for interobserver and intraobserver error analysis.

RESULTS

Linear relationship between spine length, and gestational age, biparietal diameter and CRL were demonstrated. Spine length (millimetres) as a function of gestational age (days) was expressed by the regression equation: spine length = 1.09 x (gestational age in days) -60.56, with a determination coefficient of R(2) = 0.744. Spine length ranged from 21.5 mm at 11 weeks to 41.9 mm at 14 weeks.

CONCLUSION

The data obtained showed that spine length increased progressively from the end of the first trimester to the beginning of the second. A high correlation between spine length, gestational age, biparietal diameter, and CRL was observed. Spine length measurement could therefore be considered a good indicator of fetal growth.

Characterisation of hypertensive patients according to 24 H peripheral resistance

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

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

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

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

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

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

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

Chronic pelvic pain: oral contraceptives and non-steroidal anti-inflammatory compounds

A correct classification of female pelvic pain originating from gynaecological disorders is essential if the most appropriate therapy is to be chosen. Certain types of non-steroidal anti-inflammatory drugs and oral contraceptives reduce the production of prostaglandins, which are responsible in large part for primary dysmenorrhoea. Oestroprogestin formulations become the drugs of choice if the patient also requests contraception. Secondary dysmenorrhoea and chronic pelvic pain may require combined medical and surgical treatment. Oral contraceptives can also be used as post-treatment agents in endometriosis, one of the most common causes of pelvic pain, whereas more specific compounds (GnRH-analogues and Danazol) are used to produce anatomical regression of endometriosis.

Noninvasive risk stratification in women with uncomplicated acute myocardial infarction

The aim of our study was to compare the prognostic value of stress echocardiography and exercise electrocardiography after uncomplicated non-Q-wave acute myocardial infarction in a series of 89 female patients. Our data show that stress echocardiography has independent predictive value in a female patient population recovering from uncomplicated acute myocardial infarction.

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

OBJECTIVES

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

DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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