Showing papers by "Giuseppe Mancia published in 2008"

Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes.

Abstract: BACKGROUND: In patients with type 2 diabetes, the effects of intensive glucose control on vascular outcomes remain uncertain. METHODS: We randomly assigned 11,140 patients with type 2 diabetes to undergo either standard glucose control or intensive glucose control, defined as the use of gliclazide (modified release) plus other drugs as required to achieve a glycated hemoglobin value of 6.5% or less. Primary end points were composites of major macrovascular events (death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke) and major microvascular events (new or worsening nephropathy or retinopathy), assessed both jointly and separately. RESULTS: After a median of 5 years of follow-up, the mean glycated hemoglobin level was lower in the intensive-control group (6.5%) than in the standard-control group (7.3%). Intensive control reduced the incidence of combined major macrovascular and microvascular events (18.1%, vs. 20.0% with standard control; hazard ratio, 0.90; 95% confidence interval [CI], 0.82 to 0.98; P=0.01), as well as that of major microvascular events (9.4% vs. 10.9%; hazard ratio, 0.86; 95% CI, 0.77 to 0.97; P=0.01), primarily because of a reduction in the incidence of nephropathy (4.1% vs. 5.2%; hazard ratio, 0.79; 95% CI, 0.66 to 0.93; P=0.006), with no significant effect on retinopathy (P=0.50). There were no significant effects of the type of glucose control on major macrovascular events (hazard ratio with intensive control, 0.94; 95% CI, 0.84 to 1.06; P=0.32), death from cardiovascular causes (hazard ratio with intensive control, 0.88; 95% CI, 0.74 to 1.04; P=0.12), or death from any cause (hazard ratio with intensive control, 0.93; 95% CI, 0.83 to 1.06; P=0.28). Severe hypoglycemia, although uncommon, was more common in the intensive-control group (2.7%, vs. 1.5% in the standard-control group; hazard ratio, 1.86; 95% CI, 1.42 to 2.40; P<0.001). CONCLUSIONS: A strategy of intensive glucose control, involving gliclazide (modified release) and other drugs as required, that lowered the glycated hemoglobin value to 6.5% yielded a 10% relative reduction in the combined outcome of major macrovascular and microvascular events, primarily as a consequence of a 21% relative reduction in nephropathy. (ClinicalTrials.gov number, NCT00145925.)

European Society of Hypertension guidelines for blood pressure monitoring at home: a summary report of the Second International Consensus Conference on Home Blood Pressure Monitoring.

Abstract: This document summarizes the available evidence and provides recommendations on the use of home blood pressure monitoring in clinical practice and in research. It updates the previous recommendations on the same topic issued in year 2000. The main topics addressed include the methodology of home blood pressure monitoring, its diagnostic and therapeutic thresholds, its clinical applications in hypertension, with specific reference to special populations, and its applications in research. The final section deals with the problems related to the implementation of these recommendations in clinical practice.

Discontinuation of and changes in drug therapy for hypertension among newly-treated patients: a population-based study in Italy.

Abstract: ObjectivesTo assess rates and determinants of treatment discontinuation of or changes in initial antihypertensive drug therapy in a large cohort of patients from Lombardia (Italy).MethodsThe cohort included 445 356 patients aged 40 –80 years who received their first antihypertensive drug prescriptio

Adrenergic, Metabolic, and Reflex Abnormalities in Reverse and Extreme Dipper Hypertensives

Abstract: Limited information is available on whether and to what extent the different patterns of the nocturnal blood pressure profile reported in hypertension are characterized by differences in sympathetic drive that may relate to, and account for, the different day-night blood pressure changes. In 34 untreated middle-aged essential hypertensive dippers, 17 extreme dippers, 18 nondippers, and 10 reverse dippers, we assessed muscle sympathetic nerve traffic, heart rate, and beat-to-beat arterial blood pressure at rest and during baroreceptor deactivation and stimulation. Measurements were also performed in 17 age-matched dipper normotensives. All patients displayed reproducible blood pressure patterns at 2 different monitoring sessions. The 4 hypertensive groups did not differ by gender or 24-hour or daytime blood pressure. Muscle sympathetic nerve traffic was significantly higher in nondipper, dipper, and extreme dipper hypertensives than in normotensive controls (58.61.8, 55.60.9, and 53.30.8 versus 43.51.4 bursts/100 heartbeats, respectively; P0.01 for all), a further significant increase being detected in reverse dippers (76.83.1 bursts/100 heartbeats; P0.05). Compared with normotensives, baroreflex-heart rate control was similarly impaired in all the 4 hypertensive states, whereas baroreflex-sympathetic control was preserved. The day-night blood pressure difference correlated inversely with sympathetic nerve traffic (r0.76; P0.0001) and homeostasis model assessment index (r0.32; P0.005). Thus, the reverse dipping state is characterized by a sympathetic activation greater for magnitude than that seen in the other conditions displaying abnormalities in nighttime blood pressure pattern. The present data suggest that in hypertension, sympathetic activation represents a mechanism potentially responsible for the day-night blood pressure difference. (Hypertension. 2008;52:925-931.)

The metabolic syndrome in hypertension: European society of hypertension position statement.

Abstract: The metabolic syndrome considerably increases the risk of cardiovascular and renal events in hypertension. It has been associated with a wide range of classical and new cardiovascular risk factors as well as with early signs of subclinical cardiovascular and renal damage. Obesity and insulin resistance, beside a constellation of independent factors, which include molecules of hepatic, vascular, and immunologic origin with proinflammatory properties, have been implicated in the pathogenesis. The close relationships among the different components of the syndrome and their associated disturbances make it difficult to understand what the underlying causes and consequences are. At each of these key points, insulin resistance and obesity/proinflammatory molecules, interaction of demographics, lifestyle, genetic factors, and environmental fetal programming results in the final phenotype. High prevalence of end-organ damage and poor prognosis has been demonstrated in a large number of cross-sectional and a few number of prospective studies. The objective of treatment is both to reduce the high risk of a cardiovascular or a renal event and to prevent the much greater chance that metabolic syndrome patients have to develop type 2 diabetes or hypertension. Treatment consists in the opposition to the underlying mechanisms of the metabolic syndrome, adopting lifestyle interventions that effectively reduce visceral obesity with or without the use of drugs that oppose the development of insulin resistance or body weight gain. Treatment of the individual components of the syndrome is also necessary. Concerning blood pressure control, it should be based on lifestyle changes, diet, and physical exercise, which allows for weight reduction and improves muscular blood flow. When antihypertensive drugs are necessary, angiotensin-converting enzyme inhibitors, angiotensin II-AT1 receptor blockers, or even calcium channel blockers are preferable over diuretics and classical beta-blockers in monotherapy, if no compelling indications are present for its use. If a combination of drugs is required, low-dose diuretics can be used. A combination of thiazide diuretics and beta-blockers should be avoided.

Comparison between angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on the risk of myocardial infarction, stroke and death: a meta-analysis.

Abstract: Objectives To compare the effects of angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors on the risk of myocardial infarction, stroke, cardiovascular mortality and total mortality. Methods We conducted a meta-analysis of randomized comparative trials between angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors. Inclusion criteria were publication in peer-reviewed journals indexed in Medline, randomized comparison of angiotensin II receptor blockers vs. angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers + angiotensin-converting enzyme inhibitors vs. angiotensin-converting enzyme inhibitors, report of major complications including myocardial infarction, stroke, cardiovascular mortality or all-cause mortality; average follow-up of at least 1 year in at least 200 patients. Results Six trials fulfilled the inclusion criteria, for a total of 49 924 patients. In the pooled estimate, there were no significant differences between angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors on the risk of myocardial infarction (odds ratio 1.01; 95% confidence interval 0.95–1.07; P = 0.75), cardiovascular mortality (odds ratio 1.03; 95% confidence interval 0.98–1.08; P = 0.23) and total mortality (odds ratio 1.03; 95% confidence interval 0.97–1.10; P = 0.20). This was the case also when the analysis involved only the comparison between angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers. Overall, the risk of stroke was slightly lower with angiotensin II receptor blockers than angiotensin-converting enzyme inhibitors (odds ratio 0.92; 95% confidence interval 0.85–0.99; P = 0.037), the direct angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers comparison showing a nonsignificant trend in a similar direction. Statistical heterogeneity among trials was not significant, with a low to null inconsistency statistic, for stroke (P = 0.67), myocardial infarction (P = 0.86), cardiovascular mortality (P = 0.14) and total mortality (P = 0.12). Conclusion This overview suggests that angiotensin II receptor blockers are as effective as angiotensin-converting enzyme inhibitors on the risk of myocardial infarction, cardiovascular mortality and total mortality. Angiotensin II receptor blockers may be slightly more protective than angiotensin-converting enzyme inhibitors on the risk of stroke.

Daytime sleepiness and neural cardiac modulation in sleep-related breathing disorders.

Abstract: Sleep-related breathing disorders are common causes of excessive daytime sleepiness, a socially and clinically relevant problem. Mechanisms responsible for daytime sleepiness are still largely unknown. We investigated whether specific alterations in autonomic cardiac modulation during sleep, commonly associated with sleep-related breathing disorders, are related to excessive daytime sleepiness. Fifty-three patients with sleep-related breathing disorders underwent nocturnal polysomnography. Excessive daytime sleepiness was diagnosed as a Multiple Sleep Latency Test response less than or equal to 600 s. We explored the relation of excessive daytime sleepiness, objectively determined, with indices of autonomic cardiac regulation, such as baroreflex sensitivity and heart rate variability, with polysomnographic indices of the severity of sleep-related breathing disorders and with quality of sleep. Patients with excessive daytime sleepiness, when compared with patients without, had significantly lower baroreflex sensitivity and significantly higher low-to-high frequency power ratio of heart rate variability during the different stages of nocturnal sleep. By contrast, no differences were found in indices quantifying the severity of sleep-related breathing disorders or sleep quality. We demonstrated that excessive daytime sleepiness is accompanied by a deranged cardiac autonomic control at night, the latter probably reflecting autonomic arousals not detectable in the EEG. As abnormal autonomic regulation is also known to be associated with increased cardiovascular risk, a possible relation between excessive daytime sleepiness and cardiovascular events in patients with sleep-related breathing disorders deserves to be investigated in future studies.

Achieving blood pressure goals globally: five core actions for health-care professionals. A worldwide call to action.

Abstract: The prevalence of hypertension continues to rise across the world, and most patients who receive medical intervention are not adequately treated to goal. A Working Group including representatives of nine international health-care organizations was convened to review the barriers to more effective blood pressure control and propose actions to address them. The group concluded that tackling the global challenge of hypertension will require partnerships among multiple constituencies, including patients, health-care professionals, industry, media, health-care educators, health planners and governments. Additionally, health-care professionals will need to act locally with renewed impetus to improve blood pressure goal rates. The Working Group identified five core actions, which should be rigorously implemented by practitioners and targeted by health systems throughout the world: (1) detect and prevent high blood pressure; (2) assess total cardiovascular risk; (3) form an active partnership with the patient; (4) treat hypertension to goal and (5) create a supportive environment. These actions should be pursued with vigour in accordance with current clinical guidelines, with the details of implementation adapted to the economic and cultural setting.

Long-term risk of diabetes, hypertension and left ventricular hypertrophy associated with the metabolic syndrome in a general population.

Abstract: OBJECTIVES: Metabolic syndrome is accompanied by an increased risk of developing diabetes mellitus. Limited or no evidence exists on whether and to what extent metabolic syndrome increases the risk of developing office hypertension, daily-life hypertension and left ventricular hypertrophy. METHODS: In 1412 individuals representative of the population of Monza, plasma glucose, office, home and ambulatory blood pressure, and echocardiographic left ventricular mass index were measured between 1990 and 1992 and 10 years later. New onset diabetes mellitus, new onset office, home and ambulatory hypertension as well as new onset left ventricular hypertrophy were assessed in individuals with and without metabolic syndrome (Adult Treatment Panel criteria) at the first examination. RESULTS: New onset diabetes mellitus, hypertension and left ventricular hypertrophy were all much more frequent in individuals with metabolic syndrome than in those without. In patients with metabolic syndrome, the adjusted risk of new onset diabetes mellitus was five to six times greater (P < 0.001), that of new onset office, home or ambulatory hypertension 3.5, 2.9 and 3.2 times greater (P < 0.001), respectively, and that of new onset left ventricular hypertrophy 2.6 times greater (P < 0.001). The most important predictors of new onset diabetes mellitus, hypertension and left ventricular hypertrophy were the baseline blood glucose, blood pressure and left ventricular mass index, respectively, with an independent contribution, in each condition, from other metabolic syndrome components. The metabolic syndrome as such did not have an additional predictive value. CONCLUSION: In the general population, metabolic syndrome is associated with a marked increase in the risk not only of new onset diabetes mellitus but also of new onset office and daily-life hypertension, and left ventricular hypertrophy. This may account for the increased rate of cardiovascular morbidity and mortality exhibited with this condition in long-term studies.

Italian society of hypertension guidelines for conventional and automated blood pressure measurement in the office, at home and over 24 hours.

Abstract: This article offers instructions and recommendations on how to perform blood pressure measurements in the doctor’s office, in the patient’s home and in ambulatory conditions over 24 hours. Great attention is paid to some of the general aspects of blood pressure measurement, including the accuracy of blood pressure measuring devices, the importance of a ‘white-coat effect’, and the need for patient education. This article also deals with a number of practical details, such as the importance of patient’s relaxation and position, arm position and support, arm selection and cuff selection and application. Recommendations are provided on the observer’s position and performance, and on the need to pay attention to specific factors affecting the blood pressure measurement in different patient populations, namely in children, elderly and obese people, pregnant women, patients with arrhythmias and patients on treatment. This article then separately focuses on the characteristics of auscultatory and automated measurements, the latter performed either in the office, at home or over 24 hours in ambulatory settings. Home blood pressure monitoring (HBPM) is becoming increasingly important in the diagnosis and management of arterial hypertension. The importance of HBPM in cardiovascular prevention, related to a deeper involvement of patients in their long-term management, and the wide diffusion of this approach in populations, is not always accompanied by adequate knowledge of how to make proper use of this technique, which emphasizes the need for more precise recommendations. This article summarizes the available evidence and provides recommendations on the use of home blood pressure monitoring in clinical practice and in research. It updates the previous recommendations on the same topic issued in 2000. The main topics addressed include the methodology of HBPM, focusing on measurement conditions and procedures, ranging from patient/subject position, to arm selection, arm position and support, cuff selection and application and data reporting, diagnostic and therapeutic thresholds, clinical applications in hypertension (with specific reference to special populations) and its applications in research. Special attention is given to device validation and selection as well as to patient education and to the need of HBPM to be guided by the physician in charge. The final section deals with the problems related to the implementation of these recommendations in clinical practice. Finally, the methodology and clinical impact of 24-hour ambulatory blood pressure monitoring are also addressed in detail, focusing on the parameters that can be derived from the analysis of 24-hour blood pressure recordings applied both to the diagnostic and prognostic evaluation of hypertensive patients and to the assessment of the effectiveness of antihypertensive treatment in controlling blood pressure through the day and night. Instructions to users on how to properly perform HBPM are provided as an appendix.

Simultaneous Measurement of Beat-to-Beat Carotid Diameter and Pressure Changes to Assess Arterial Mechanical Properties

Abstract: Use of local arterial distensibility measurements by change in carotid artery diameter divided by pulse pressure has limitations because blood pressure is often taken in a vessel distant or at a time different from where and when change in diameter is taken. In 92 subjects (23 to 91 years of age), carotid artery diameter was continuously measured ecographically, whereas blood pressure was continuously measured simultaneously tonometrically on the contralateral artery, the 2 signals being synchronized via 2 EKGs. Within each cardiac cycle, there was a linear relationship between the changes in vessel diameter and the changes in blood pressure during either the protomesosystole or the diastole after the dicrotic notch. The diastolic slope was displaced upward and steeper than the systolic slope, the pressure-diameter loop showing a hysteresis. Both slopes showed a high reproducibility when data were averaged over a several-second period. There were small differences between consecutive cardiac cycles, suggesting that modulation of arterial mechanical response to continuous changes in intravascular pressure may undergo physiological variations. In the 92 subjects, systolic and diastolic slopes correlated significantly with distensibility values obtained by Reneman formula and exhibited a close inverse relationship with each subject's age and systolic blood pressure, thereby showing the ability to reflect age- and pressure-dependent large artery stiffening. This method may allow precise assessment of man's arterial mechanical properties within each cardiac cycle. This highly dynamic assessment may help to collect information on properties of normal and altered large elastic arteries and the mechanisms involved in disease.

The safety profile of telmisartan as monotherapy or combined with hydrochlorothiazide: A retrospective analysis of 50 studies

Abstract: Background To compare the tolerability and safety of telmisartan +/- hydrochlorothiazide (HCTZ). Methods This retrospective analysis was performed on all hypertensive patients that were enrolled in telmisartan studies. A total of 30 double-blind (n=8023) and 20 open-label (n=8393) studies were available at the time of this analysis, and were included. Treatments investigated were placebo, telmisartan 10-160 mg, or telmisartan 10-160 mg plus HCTZ 6.25-25 mg. The incidence and causality of all adverse events (AEs) and laboratory abnormalities occurring during treatment were recorded. Results The incidences of all-cause AEs in the double-blind studies were: 2.73 per patient-year (PY) (36.1%; placebo); 2.03/PY (37.4%; telmisartan monotherapy) and 2.09/PY (44.8%; telmisartan plus HCTZ). The respective numbers in the open-label studies were: 0.65/PY (49.6%; telmisartan monotherapy) and 0.70/PY (40.3%; telmisartan plus HCTZ). The most frequent suspected adverse reactions were dizziness and headache, which were comparable across groups and studies. The overall incidence of drug-related laboratory abnormalities was low in all treatment groups. Treatment-related hyperuricaemia and hypokalaemia occurred in less than 0.1% of patients, respectively, treated with telmisartan plus HCTZ. Incidences of discontinuation due to an AE were 4.6%, 4.5% and 4.7%, respectively, for the placebo, telmisartan and telmisartan plus HCTZ treatment groups. Conclusion The consolidated data show that telmisartan +/- HCTZ are well tolerated in patients of all ages and have placebo-like tolerabilities.

Choice of antihypertensive drugs in the European Society of Hypertension-European Society of Cardiology guidelines: specific indications rather than ranking for general usage.

Abstract: The 2007 European Society of Hypertension–European Society of Cardiology guidelines [1] have addressed in detail the position of b-blockers in the treatment of hypertension as well as the reasons that have led some guidelines [2] to recommend them only as fourth choice step, with their virtual removal from routine antihypertensive treatment. They came to the conclusion that a critical examination of the overall available evidence by no means justifies such a drastic decision but it only clarifies more precisely in which clinical conditions b-blockers should or should not be preferred. Indeed, in our opinion, considerations upon which choice of drugs should be based are of two different orders, factual considerations on pros and cons of each drug and more general considerations on the way the choice of antihypertensive drugs should be approached.

Device-guided paced breathing in the home setting: effects on exercise capacity, pulmonary and ventricular function in patients with chronic heart failure: a pilot study.

Abstract: Background— Regular slow breathing is known to improve autonomic cardiac regulation and reduce chemoreflex sensitivity in heart failure. We explored the acceptability and usefulness of a device for paced slow breathing at the home setting. Methods and Results— In this open pilot study, 24 patients with chronic heart failure (61% males, mean age, 64�9 years; New York Heart Association class, 2.81�0.01) were randomized to a control group receiving conventional treatment (n=12) or to a group receiving conventional treatment and device-guided paced breathing (n=12). Groups were comparable for age, therapies, and clinical characteristics. They were evaluated at baseline and again after 10 weeks by Doppler echocardiography, pulmonary function, cardiopulmonary stress test, and quality of life (Minnesota Quality of Life questionnaire). The treatment group was instructed to use the equipment for 18 minutes twice daily. The device is a computerized box connected to a belt-type respiration sensor and to headphones; ...

Essential hypertension and the sympathetic nervous system

Abstract: Sympathetic neural factors exert a key role in homeostatic blood pressure control. Evidence is available that abnormalities in sympathetic function may favour the development and progression of the hypertensive state. This paper will review the data collected throughout the years on the role of adrenergic mechanisms in the pathophysiology of the hypertensive state. It will then examine the mechanisms and the consequences of the sympathetic overdrive reported in hypertension, with particular emphasis on its role in the development of target organ damage. Finally the therapeutic implications of hypertension-related neurogenic abnormalities will be highlighted.

Sympathetic activation in congestive heart failure: Reproducibility of neuroadrenergic markers

Abstract: Objective: To assess the reproducibility of the two markers of adrenergic drive, venous plasma norepinephrine (NE) and efferent postganglionic muscle sympathetic nerve activity (MSNA), in reflecting the sympathetic activation characterizing congestive heart failure (CHF). Methods and measurements: In 19 CHF male normotensive patients (mean age: 53.0±2.1 years, NYHA classes II and III, left ventricular ejection fraction 35.9±2.9%), blood pressure (BP, Finapres), heart rate (EKG), plasma NE (HPLC assay) and MSNA (microneurography, peroneal nerve) were measured in two experimental sessions separated by a week interval. At each session, three NE samples were obtained and NE reproducibility between sessions was assessed by considering single NE samples or averaging 2–3 samples. Results: While MSNA values showed a highly significant correlation between sessions (r = 0.85, P<0.001), NE values based on a single blood sample evaluation did not correlate with each other (r = 0.41, P = NS). NE correlation coefficients improved and achieved statistical significance when average data from 2 and 3 blood samples were examined (r = 0.54 and r = 0.57, P<0.02 for both). Conclusions: In CHF, MSNA displays a better reproducibility pattern than plasma NE. The reproducibility of the NE approach, however, can be improved by performing the assay on multiple blood samples.

Editorial: The new European Society of Hypertension/European Society of Cardiology (ESH/ESC) Guidelines

Abstract: The 2007 guidelines on hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) [Mancia et al. 2007] differ for several aspects from the previous hypertension guidelines issued by the two Societies in 2003 [Guidelines Committee ESH/ESC, 2003]. In some instances the difference mainly consists in a reinforcement or extension of what was only suggested by the previous guidelines, based on the increased amount of data obtained in the last four years. In other instances, however, it consists in an actual change from what was recommended in 2003 because of the new data provided by trials and other types of studies. In this paper we will report on some of these differences and discuss their rationale.

Increased Arterial Stiffness in Normoglycemic Normotensive Offspring of Type 2 Diabetic Parents

Abstract: Diabetes is associated with a reduction of arterial distensibility. Limited information exists regarding whether or how early this appears in the course of the disease. We studied 54 normoglycemic, normotensive, healthy offspring of 2 parents with type 2 diabetes mellitus and 55 age- and sex-matched healthy control subjects. Carotid diastolic diameter and systodiastolic change were measured by echo tracking (Wall Track System) and wall thickness by echocolor Doppler (Sonos 5500, Philips). Pulse pressure was measured by a semiautomatic device positioned on the brachial artery and arterial distensibility calculated by Reneman formula. Blood pressure, blood glucose, glycohemoglobin, and insulin sensitivity (homeostasis model assessment index) were normal or only slightly elevated and by and large similar in the 2 groups. Compared with control subjects, offspring of diabetic parents showed similar carotid diameters at diastole and a reduced increase in carotid diameter at systole (−16%), a reduced carotid artery distensibility (−30%), and an increased pulse pressure (+21.8%), all differences being statistically significant ( P 2 ). Carotid artery wall thickness was not different between the 2 groups. Thus, subjects with predisposition to diabetes show carotid artery stiffening even in the absence of blood pressure alterations, as well as substantial alterations of glucose metabolism, body mass index, and changes in carotid wall thickness. This suggests that, in diabetes, alterations in arterial mechanical properties represent an early phenomenon, which may occur in the absence of metabolic and blood pressure alterations.

Body mass index, nocturnal fall in blood pressure and organ damage in untreated essential hypertensive patients.

Abstract: AIM We sought to investigate the relationship between body mass index (BMI) and parameters derived from 48-h ambulatory blood pressure monitoring (ABPM) as well as organ damage in human hypertension. METHODS A total of 658 consecutive outpatients with grade 1 and 2 hypertension, never treated with antihypertensive medications underwent the following procedures: (i) routine examination, (ii) 24-h urine collection for microalbuminuria, (iii) ABPM over two 24-h periods within 4 weeks, (iv) echocardiography and (v) carotid ultrasonography. Each patient was classified as lean (BMI or =25 kg/m2) and according to the consistency of the dipping or nondipping status in the first and second ABPM period, as dipper (DD), nondipper and variable dipper. RESULTS Mean 48-h, daytime and nighttime systolic BP or diastolic BP were superimposable in the lean (n=314) and overweight (n=344) group. Overweight patients had a reduced nocturnal BP drop compared with their lean counterparts; the prevalence of DD pattern, indeed, was 15% lower in the overweight group as a whole, with a 17% difference in men and 13% in women. The prevalence of left ventricular hypertrophy was higher in overweight than in lean patients (31.8 vs. 15.9% in men and 48.7 vs. 15.6% in women, P<0.01); this more pronounced cardiac involvement was associated with structural carotid alterations. CONCLUSION This study, the first to investigate the relationship between BMI and nocturnal BP patterns as assessed by two ABPM sessions, shows that overweight hypertensive patients are more likely to have a reduced nocturnal fall in BP and a greater cardiac and extracardiac organ damage as compared with their lean counterparts despite a similar overall BP load.

Prevalence of type 2 diabetes among patients with hypertension under the care of 30 Italian clinics of hypertension: Results of the (Iper)tensione and (dia)bete study

Abstract: BACKGROUND AND PURPOSE Hypertension is known to be highly prevalent among patients with diabetes and associated with an increased risk of cardiovascular damage. In contrast, relatively few investigations have addressed the prevalence of diabetes among patients with hypertension. The purpose of the present study was to examine the prevalence of type 2 diabetes, the effectiveness of hypertension and diabetes control and the association with other cardiovascular risk factors and previous cardiovascular diseases in a cohort of patients with hypertension referred to 30 hospital outpatient clinics for the treatment of hypertension. METHODS AND PATIENTS Patients were considered as having diabetes if they were already on an antidiabetic treatment either with diet or medications. All other patients had fasting plasma glucose measured on two separate occasions and were classified as having diabetes if both values were at least 140 mg/dl (7.8 mmol/l) and as not having diabetes if both values were less than 110 mg/dl (6.1 mmol/l). In patients with a single determination of at least 110 mg/dl, the final diagnosis of diabetes was established according to the result of an oral glucose tolerance test. A secondary definition of diabetes was also used, that is two fasting plasma glucose values of at least 126 mg/dl (7.0 mmol/l). In all patients, serum total, high-density lipoprotein cholesterol and low-density lipoprotein cholesterol, fasting serum triglycerides, serum creatinine and urinary albumin were also evaluated. RESULTS AND CONCLUSION Among the 1397 recruited patients, 242 (17.3%) were diagnosed as having diabetes according to the primary definition and 244 (17.5%) according to the secondary definition. In 195 out of the 242 (14%), the diagnosis was already known whereas, in the remaining 47 (3.3%), it was made de novo. In 61.4% of those already having diabetes, plasma glucose was at least 140 mg/dl (7.8 mmol/l), whereas only in 8.4% of them was it less than 110 mg/dl (6.1 mmol/l). Patients with diabetes were older, heavier and with a greater familiar predisposition. Patients with diabetes had higher values of systolic blood pressure than individuals without diabetes (150 +/- 17 vs. 144 +/- 16 mmHg, respectively; P < 0.001), lower high-density lipoprotein cholesterol and higher triglycerides and microalbuminuria. Overall, among patients with hypertension and diabetes, only 3% had blood pressure and HbA1c within the recommended limits. The prevalence of previous cardiovascular disorders was two to three times higher than among individuals without diabetes.

Metabolic syndrome and multiple organ damage in essential hypertension

Abstract: Aim. We investigated the prevalence of the metabolic syndrome (MS) in hypertensive patients categorized according to the number of markers of organ damage (OD) in order to assess the value of a sys...

Spotlight on Renin

Abstract: The High Blood Pressure Research Conference of the American Heart Association is a theoretical meeting for hypertension researchers who direct their attention to hypertension-related basic disease mechanisms. The items that I have selected for this brief review are molecular intracellular receptor function, novel angiotensin (Ang)-related pathways, including Ang-(1-7), the Mas receptor, and angiotensin-converting enzyme 2, oxidative stress, immunity, the (pro)renin receptor, and until now unappreciated signalling pathways, such as the tonicity element binding protein.

Prevalence and correlates of multiple organ damage in a never-treated hypertensive population: role of ambulatory blood pressure.

Abstract: AIM Available evidence on multiple target organ damage (TOD) in the early phases of essential hypertension is scanty. We examined the prevalence and correlates of multiple TOD in never-treated patients with recently diagnosed hypertension. METHODS A total of 602 consecutive outpatients with grades 1 and 2 hypertension underwent the following procedures: (i) routine examination, (ii) 24-h urine collection for microalbuminuria, (iii) ambulatory blood pressure monitoring over two 24-h periods within 4 weeks, (iv) echocardiography, (v) carotid ultrasonography. TOD at cardiac, vascular and renal levels was defined according to major international hypertension guidelines. RESULTS Prevalence rates of patients negative for TOD (group I) or positive for one (group II), two (group III), or three (group IV) markers of TOD were as follows: 45, 33, 17 and 5%. In group II, alterations in left ventricular structure and geometry were more frequently present than carotid atherosclerosis and microalbuminuria; a similar trend was found in group III where a close association between cardiac and vascular, but not renal, signs of TOD was observed. In multiple regression analyses the risk of having three TOD was significantly related to age [odds ratio (OR): 2.11, 95% confidence interval (CI): 1.34-3.53], average 48-h systolic blood pressure (OR: 1.81, 95% CI: 1.22-2.95), smoking status (OR: 1.76, 95% CI: 1.22-2.86), male sex (OR: 1.36, 95% CI: 1.24-1.79), reproducible nondipping pattern (OR: 1.27, 95% CI: 1.12-1.61) and metabolic syndrome (OR: 1.16, 95% CI: 1.09-1.74). CONCLUSIONS Our results show that: (i) a cluster of three TOD, namely at cardiac, carotid and renal levels, is not a common finding in a population of untreated essential hypertensive patients; a single TOD is present in about one-third of the patients and the parallel involvement of two organs in one-fifth of the cases; (ii) old age, ambulatory systolic blood pressure and smoking status are the most important predictors of multiple organ involvement.

Adrenergic, Metabolic, and Reflex Abnormalities in Reverse and Extreme Dipper Hypertensives. Commentary

Abstract: -Limited information is available on whether and to what extent the different patterns of the nocturnal blood pressure profile reported in hypertension are characterized by differences in sympathetic drive that may relate to, and account for, the different day-night blood pressure changes. In 34 untreated middle-aged essential hypertensive dippers, 17 extreme dippers, 18 nondippers, and 10 reverse dippers, we assessed muscle sympathetic nerve traffic, heart rate, and beat-to-beat arterial blood pressure at rest and during baroreceptor deactivation and stimulation. Measurements were also performed in 17 age-matched dipper normotensives. All patients displayed reproducible blood pressure patterns at 2 different monitoring sessions. The 4 hypertensive groups did not differ by gender or 24-hour or daytime blood pressure. Muscle sympathetic nerve traffic was significantly higher in nondipper, dipper, and extreme dipper hypertensives than in normotensive controls (58.6±1.8, 55.6±0.9, and 53.3±0.8 versus 43.5±1.4 bursts/100 heartbeats, respectively; P<0.01 for all), a further significant increase being detected in reverse dippers (76.8±3.1 bursts/100 heartbeats; P<0.05). Compared with normotensives, baroreflex-heart rate control was similarly impaired in all the 4 hypertensive states, whereas baroreflex-sympathetic control was preserved. The day-night blood pressure difference correlated inversely with sympathetic nerve traffic (r=-0.76; P<0.0001) and homeostasis model assessment index (r= -0.32; P<0.005). Thus, the reverse dipping state is characterized by a sympathetic activation greater for magnitude than that seen in the other conditions displaying abnormalities in nighttime blood pressure pattern. The present data suggest that in hypertension, sympathetic activation represents a mechanism potentially responsible for the day-night blood pressure difference.

Cardioprotective effects of telmisartan in uncomplicated and complicated hypertension.

Abstract: The development of angiotensin II receptor blockers (ARB) as a new class of drugs for the management of hypertension has elicited the attention of many clinicians worldwide with the aim of improving blood pressure (BP) control as well as cardiovascular protection.AmongARB telmisartan has been shown to be characterised by an antihypertensive efficacy fully covering the 24-hour period, thereby allowing to antagonise the adverse effects of early morning BP rise on cardiovascular risk. Other specific effects of the drug are represented by its favourable metabolic profile (particularly on insulin sensitivity) and neutral effects on sympathetic cardiovascular function.These properties are coupled with cardioprotective effects, documented by the evidence that the drug: 1) is effective in favouring the regression of cardiac and vascular organ damage, 2) reduces arterial stiffness and improves vascular distensibility and 3) reverses the endothelial dysfunction typical of the hypertensive state particularly when co...

Heart rate as a sympathetic marker during acute adrenergic challenge

Abstract: OBJECTIVE Previous studies have shown that heart rate has a limited value in reflecting the chronic state of adrenergic overdrive characterizing several cardiovascular diseases. Whether this also applies to the ability of heart rate to reflect acute and generalized changes in sympathetic activity is unknown. METHODS In 20 healthy young subjects (age: 25.2 +/- 1.2 years, mean +/- SEM) we measured beat-to-beat blood pressure (Finapres), heart rate (HR, ECG), venous plasma norepinephrine (NE, high-performance liquid chromatography) and efferent postganglionic muscle sympathetic nerve traffic (MSNA, microneurography) at rest and during a cold pressor test and two intravenous infusions of nitroprusside at increasing doses. RESULTS Both cold pressor test and nitroprusside infusions triggered marked and significant increases in HR, plasma NE and MSNA; blood pressure showing an increase with cold pressor test and a reduction with nitroprusside. The magnitude of the responses was greater with the higher than with the lower dose of nitroprusside. The HR changes induced by cold pressor test were not significantly related to the concomitant NE and MSNA changes (r = -0.08 and r = -0.18, P = NS). This was also the case for the lower and the higher dose of nitroprusside (NE: r = -0.11 and r = 0.08; MSNA: r = 0.01 and r = -0.11, P = NS for all). In contrast NE and MSNA changes induced by cold pressor test and by the lower and the higher dose of nitroprusside were significantly related to each other (r = 0.70, r = 0.89 and r = 0.79 respectively, P < 0.01 for all). CONCLUSIONS In a given individual, HR responses to sympathetic challenge do not quantitatively reflect the degree of acute and generalized adrenergic activation. Qualitative information on the acute adrenergic effects of given stimuli should thus be based on the assessment of NE and MSNA rather than on HR changes.