Showing papers by "Giuseppe Mancia published in 2009"
University of Milano-Bicocca1, University of Paris2, University of Brescia3, University of Bologna4, University of Lausanne5, Queen Mary University of London6, Ghent University7, University of Barcelona8, University of Glasgow9, Istanbul University10, Katholieke Universiteit Leuven11, Hannover Medical School12, University of Manchester13, University of Oslo14, Joseph Fourier University15, Gdańsk Medical University16, University of Copenhagen17, University of Münster18, University of Valencia19, Complutense University of Madrid20, University of Erlangen-Nuremberg21, Maastricht University22, University of Amsterdam23, University of Milan24
TL;DR: The objective of this study was to establish a baseline for the design of a systematic literature review of this type of treatment for high blood pressure using a simple, straightforward, and scalable procedure.
Abstract: Abbreviations ACE: angiotensin-converting enzyme; BP: blood pressure; DBP: diastolic blood pressure; eGFR: estimated glomerular filtration rate; ESC: European Society of Cardiology; ESH: European Society of Hypertension; ET: endothelin; IMT: carotid intima-media thickness; JNC: Joint National Commit
976 citations
TL;DR: In this article, the effects of albuminuria and reduced estimated GFR (eGFR) on the risk for cardiovascular and renal events among individuals with type 2 diabetes were investigated. But, there was no evidence of an interaction between the effect of higher eGFR and lower UACR.
Abstract: There are limited data regarding whether albuminuria and reduced estimated GFR (eGFR) are separate and independent risk factors for cardiovascular and renal events among individuals with type 2 diabetes. The Action in Diabetes and Vascular disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE) study examined the effects of routine BP lowering on adverse outcomes in type 2 diabetes. We investigated the effects of urinary albumin-to-creatinine ratio (UACR) and eGFR on the risk for cardiovascular and renal events in 10,640 patients with available data. During an average 4.3-yr follow-up, 938 (8.8%) patients experienced a cardiovascular event and 107 (1.0%) experienced a renal event. The multivariable-adjusted hazard ratio for cardiovascular events was 2.48 (95% confidence interval 1.74 to 3.52) for every 10-fold increase in baseline UACR and 2.20 (95% confidence interval 1.09 to 4.43) for every halving of baseline eGFR, after adjustment for regression dilution. There was no evidence of interaction between the effects of higher UACR and lower eGFR. Patients with both UACR >300 mg/g and eGFR <60 ml/min per 1.73 m(2) at baseline had a 3.2-fold higher risk for cardiovascular events and a 22.2-fold higher risk for renal events, compared with patients with neither of these risk factors. In conclusion, high albuminuria and low eGFR are independent risk factors for cardiovascular and renal events among patients with type 2 diabetes.
751 citations
TL;DR: These guidelines represent a consensus among specialists involved in the detection and control of high blood pressure in children and adolescents and represent best clinical wisdom upon which physicians, nurses and families should base their decisions.
Abstract: Hypertension in children and adolescents has gained ground in cardiovascular medicine, thanks to the progress made in several areas of pathophysiological and clinical research. These guidelines represent a consensus among specialists involved in the detection and control of high blood pressure in children and adolescents. The guidelines synthesize a considerable amount of scientific data and clinical experience and represent best clinical wisdom upon which physicians, nurses and families should base their decisions. They call attention to the burden of hypertension in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers, to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.
655 citations
TL;DR: In high-risk patients, the benefits from SBP lowering below 130 mmHg are driven mostly by a reduction of stroke; myocardial infarction is unaffected and cardiovascular mortality is unchanged or increased.
Abstract: BackgroundHypertension guidelines advise aggressive blood pressure (BP) lowering in patients with diabetes or high cardiovascular risk, but supporting evidence is limited We analysed the impact of BP on cardiovascular events in well treated high-risk patients enrolled in a large clinical trial (Ong
334 citations
TL;DR: Critical analyses of the results of available trials show that the evidence is scanty for both recommendations, but they can be accepted as prudent statements, as antihypertensive agents are very well tolerated and lowering systolic blood pressure below 130 mmHg appears well tolerated.
Abstract: The evidence for two recommendations of all major guidelines on hypertension is critically discussed. The first recommendation is that of initiating antihypertensive drug treatment when systolic blood pressure is at least 140 or diastolic blood pressure at least 90 mmHg in patients with grade 1 hypertension and low or moderate total cardiovascular risk, and even when blood pressure is in the high normal range in patients with diabetes and previous cardiovascular disease. The second recommendation is that of achieving systolic blood pressure levels below 140 mmHg in all hypertensive patients, including the elderly, and values below 130 mmHg in patients having diabetes and high/very-high-risk patients. Critical analyses of the results of available trials show that the evidence is scanty for both recommendations. Nonetheless, they can be accepted as prudent statements, as antihypertensive agents are very well tolerated and lowering systolic blood pressure below 130 mmHg appears well tolerated. However, wisdom should not be taken for evidence, and simple trials should be designed to look for more solid evidence in favour of current recommendations.
312 citations
TL;DR: Subjects with WCHT and MHT are at increased risk of developing SHT, and independent contributors of worsening of hypertension status were not only baseline BP, but also, although to a lesser extent, metabolic variables and age.
Abstract: It is debated whether white-coat (WCHT) and masked hypertension (MHT) are at greater risk of developing a sustained hypertensive state (SHT). In 1412 subjects of the Pressioni Arteriose Monitorate e Loro Associazioni Study, we measured office blood pressure (BP), 24-hour ambulatory BP, and home BP. The condition of WCHT was identified as office BP >140/90 mm Hg and 24-hour BP mean or =125/79 mm Hg, and home BP >or =132/82 mm Hg. SHT was identified when both office and 24-hour BP means or home BP were over threshold values and normotension was under the threshold value. Subjects were reassessed 10 years later to evaluate the BP status of the various conditions defined previously. At the first examination, 758 (54.1%), 225 (16.1%), 124 (8.9%), and 293 (20.9%) subjects were normotensive, WCHT, MHT, and SHT subjects, respectively. At the second examination, 136 normotensives (18.2%), 95 WCHT (42.6%), and 56 MHT (47.1%) subjects became SHT. As compared with normotensives, adjusting for age and sex, the risk of becoming SHT was significantly higher for WCHT and MHT subjects (odds ratio: 2.51 and 1.78, respectively; P<0.0001). Similar results were obtained when the definition of the various conditions was based on home BP. Independent contributors of worsening of hypertension status were not only baseline BP, but also, although to a lesser extent, metabolic variables and age. Subjects with WCHT and MHT are at increased risk of developing SHT. This may contribute to their prognosis that appears to be worse as compared with that of normotensive subjects.
275 citations
TL;DR: BP-lowering treatment with perindopril-indapamide administered routinely to individuals with type 2 diabetes provides important renoprotection, even among those with initial BP <120/70 mmHg, and a BP threshold below which renal benefit is lost is not identified.
Abstract: BP is an important determinant of kidney disease among patients with diabetes. The recommended thresholds to initiate treatment to lower BP are 130/80 and 125/75 mmHg for people with diabetes and nephropathy, respectively. We sought to determine the effects of lowering BP below these currently recommended thresholds on renal outcomes among 11,140 patients who had type 2 diabetes and participated in the Action in Diabetes and Vascular disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE) study. Patients were randomly assigned to fixed combination perindopril-indapamide or placebo, regardless of their BP at entry. During a mean follow-up of 4.3 yr, active treatment reduced the risk for renal events by 21% (P < 0.0001), which was driven by reduced risks for developing microalbuminuria and macroalbuminuria (both P < 0.003). Effects of active treatment were consistent across subgroups defined by baseline systolic or diastolic BP. Lower systolic BP levels during follow-up, even to <110 mmHg, was associated with progressively lower rates of renal events. In conclusion, BP-lowering treatment with perindopril-indapamide administered routinely to individuals with type 2 diabetes provides important renoprotection, even among those with initial BP <120/70 mmHg. We could not identify a BP threshold below which renal benefit is lost.
250 citations
Radboud University Nijmegen1, Monash University2, University of Sydney3, French Institute of Health and Medical Research4, University of Paris5, The Heart Research Institute6, Utrecht University7, Université de Montréal8, University of Sheffield9, University of Milan10, Imperial College London11, Icahn School of Medicine at Mount Sinai12
TL;DR: Cognitive dysfunction is an independent predictor of clinical outcomes in patients with type 2 diabetes, but does not modify the effects of BP lowering or glucose control on the risks of major cardiovascular events.
Abstract: Aims/hypothesis
The relationship between cognitive function, cardiovascular disease and premature death is not well established in patients with type 2 diabetes. We assessed the effects of cognitive function in 11,140 patients with type 2 diabetes who participated in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial. Furthermore, we tested whether level of cognitive function altered the beneficial effects of the BP-lowering and glycaemic-control regimens in the trial.
177 citations
TL;DR: Evidence is provided that LVH is an important risk factor even when the contribution of different BPs to risk is fully taken into account, and left ventricular mass index was always an independent predictor of cardiovascular events and death for any cause.
Abstract: ObjectivesPrevious studies have shown that left ventricular hypertrophy (LVH) represents a cardiovascular risk factor independently of clinic blood pressure (BP). The present study was aimed at determining the impact of LVH on the incidence of cardiovascular morbid and fatal events taking into accou
163 citations
TL;DR: The data provide the first evidence that, in hypertension, activation of the sympathetic nervous system may contribute not only at the blood pressure elevation but also at the development of left ventricular diastolic dysfunction.
Abstract: The sympathetic overdrive that characterizes essential hypertension is potentiated when left ventricular hypertrophy or congestive heart failure is detected. No information exists, however, on whether this is the case also for left ventricular diastolic dysfunction. In 17 untreated hypertensive subjects with left ventricular diastolic dysfunction (age: 47.7+/-2.9 years, mean+/-SEM), we measured sympathetic nerve traffic (microneurography), heart rate (ECG), and beat-to-beat arterial blood pressure (Finapres) at rest and during baroreceptor deactivation and stimulation. Data were compared with those collected in 20 age-matched normotensive and 20 hypertensive subjects without a diastolic function impairment. Muscle sympathetic nerve traffic values were markedly and significantly greater in the 2 hypertensive groups than in the normotensive one (55.3+/-1.2 and 71.2+/-1.6 versus 41.7+/-1.0 bursts per 100 heartbeats, respectively; P<0.01 for both). For a similar blood pressure elevation, however, the sympathetic nerve traffic increase was significantly greater in patients with than without left ventricular diastolic dysfunction (+28.9%; P<0.05). In the population as a whole, muscle sympathetic nerve traffic was significantly and inversely related to various echocardiographic indices of diastolic function. Although baroreflex-heart rate control was significantly attenuated in the 2 hypertensive groups, baroreflex-sympathetic modulation was impaired only in those with diastolic dysfunction. These data provide the first evidence that, in hypertension, activation of the sympathetic nervous system may contribute not only at the blood pressure elevation but also at the development of left ventricular diastolic dysfunction. The sympathetic overactivity, which is likely to be related to the baroreflex impairment, may account for the increased cardiovascular risk characterizing diastolic dysfunction.
157 citations
TL;DR: Patients' management based on home blood pressure teletransmission led to a better control of ambulatory blood pressure than with usual care, with a more regular treatment regimen.
Abstract: BackgroundSelf blood pressure monitoring at home may improve blood pressure control and patients' compliance with treatment, but its implementation in daily practice faces difficulties. Teletransmission facilities may offer a more efficient approach to long-term home blood pressure monitoring.Method
TL;DR: ELSA shows that carotid intima-media thickening and plaques are important added risks of cardiovascular outcomes in a treated hypertensive population independently of blood pressure and traditional risk factors, but the analysis failed to show a predictive role of treatment-dependent IMT changes.
Abstract: Background— Baseline carotid intima-media thickness (IMT) and plaques are considered predictors of cardiovascular events, but whether they maintain predictive value in treated hypertensive patients and whether time-related (or treatment-induced) IMT changes are additional predictors are unknown. Methods and Results— Analyses were performed of the data from the European Lacidipine Study on Atherosclerosis (ELSA), a large, randomized, intervention trial in which 2334 hypertensive patients from 7 European countries were followed up under effective antihypertensive treatment for 3.75 years. Kaplan–Meier curves indicated progressively lower survival free of any type of outcome except stroke, with increasing baseline IMT quartiles or increasing IMT values, even after adjustment for major baseline risk factors. Incidence of any outcome except stroke also was related to baseline number of carotid plaques. However, when both baseline and on-treatment IMT values were entered in Cox proportional-hazards models, diff...
TL;DR: White-coat and masked hypertension are associated with a long-term greater progression of blood glucose abnormalities and an increased risk of developing diabetes.
Abstract: ObjectiveA sustained blood pressure elevation is associated with an increased risk of new-onset diabetes mellitus. Whether this is the case also in white-coat and masked hypertension is unknown.MethodsIn 1412 individuals of the Pressioni Arteriose Monitorate E Loro Associazioni study stratified for
McMaster University1, John Radcliffe Hospital2, Katholieke Universiteit Leuven3, University of Naples Federico II4, University of Erlangen-Nuremberg5, Catholic University of Korea6, The Heart Research Institute7, Charles University in Prague8, National Cheng Kung University9, Peking Union Medical College10, University of Washington11
TL;DR: The effect of these drugs on left ventricular hypertrophy (LVH) in high-risk patients without heart failure is unknown as mentioned in this paper, however, the effect of ACE inhibitors on LVH in high risk patients without congestive heart failure was unknown.
Abstract: Background— Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers reduce left ventricular hypertrophy (LVH). The effect of these drugs on LVH in high-risk patients without heart failure is unknown. Methods and Results— In the Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial (ONTARGET), patients at high vascular risk and tolerant of ACE inhibitors were randomly assigned to ramipril, telmisartan, or their combination (n=23 165). In the Telmisartan Randomized Assessment Study in ACE Intolerant Subjects With Cardiovascular Disease (TRANSCEND), patients intolerant of ACE inhibitors were randomized to telmisartan or placebo (n=5343). Prevalence of LVH at entry in TRANSCEND was 12.7%. It was reduced by telmisartan (10.5% and 9.9% after 2 and 5 years) compared with placebo (12.7% and 12.8% after 2 and 5 years) (overall odds ratio, 0.79; 95% confidence interval [CI], 0.68 to 0.91; P=0.0017). New-onset LVH occurred less frequently with telmisartan compared...
TL;DR: Cirrhotic patients with a more severe disease, especially of alcoholic aetiology, who have greater HVPG and lower calcium plasma levels, have an altered ventricular repolarization and a reduced vagal activity to the heart, which may predispose to life-threatening arrhythmias.
Abstract: A prolongation of QT interval has been shown in patients with cirrhosis and it is considered as part of the definition of the so-called ‘cirrhotic cardiomyopathy’ The aim of the present study was to assess the determinants of QT interval prolongation in cirrhotic patients Forty-eight male patients with different stages of liver disease were divided into three subgroups according to the Child–Pugh classification All patients underwent a 24-h ECG Holter recording The 24-h mean of QT intervals corrected for heart rate (termed QTc) and the slope of the regression line QT/RR were calculated HRV (heart rate variability), plasma calcium and potassium concentration and HVPG (hepatic venous pressure gradient) were measured QTc was progressively prolonged from Child A to Child C patients (P = 0001) A significant correlation between QTc and HVPG was found (P = 0003) Patients with alcohol-related cirrhosis presented QTc prolongation more frequently than patients with post-viral cirrhosis (P < 0001) The QT/RR slope was steeper in subjects with alcoholic aetiology as compared with viral aetiology (P = 002), suggesting that these patients have a further QTc prolongation when heart rate decreases The plasma calcium concentration was inversely correlated with QTc (P < 0001) The presence of severe portal hypertension was associated with decreased HRV (P < 0001) Cirrhotic patients with a more severe disease, especially of alcoholic aetiology, who have greater HVPG and lower calcium plasma levels, have an altered ventricular repolarization and a reduced vagal activity to the heart, which may predispose to life-threatening arrhythmias
TL;DR: In CAD patients with hypertension, PP (on anti-hypertensive treatment) is a weaker predictor of cardiovascular outcomes than SBP, DBP, or MAP.
Abstract: Aim The purpose of this study was to assess the relationship between pulse pressure (PP) and cardiovascular outcomes in a large, elderly, coronary artery disease (CAD) population with hypertension, and compare the predictive power of PP with other blood pressure measures.
Methods and results In INternational VErapamil-trandolapril STudy, 22 576 CAD patients with hypertension (mean age 66 years) were randomized to verapamil-SR or atenolol-based strategies and followed for 2.7 years (mean). Primary outcome (PO) was time to first occurrence of death (all-cause), non-fatal myocardial infarction (MI), or non-fatal stroke. Mean follow-up PP was summarized by 5 mmHg subgroups for association with incidence of PO. Stepwise Cox proportional hazards models were used to estimate adjusted relative hazard ratios (HR) for the risk of PO with follow-up PP as a continuous variable, with linear and quadratic terms. Similar models were constructed for follow-up systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressures (MAP). A −2 log-likelihood statistic was used to assess the predictive power of PP compared with SBP, DBP, and MAP. For follow-up PP, the incidence and adjusted HR for the PO formed a J- or U-shaped curve. After adjusting for baseline covariates, both linear and quadratic terms for PP were significant ( P < 0.0001 for both), with a nadir of 54 mmHg (bootstrapping 95% CI 42–60 mmHg). Similar quadratic relationships were found between PP and all-cause mortality or MI; the relationship between PP and stroke was linear. Pulse pressure was a predictor of PO even after including SBP ( P = 0.007 linear term) or DBP ( P < 0.0001 for both linear and quadratic terms) or MAP ( P < 0.01 for both liner and quadratic terms) in the model. Using −2 log-likelihood differences, SBP (−2 log-likelihood difference 77.1 vs. 7.3 for PP), DBP (−2 log-likelihood difference 138.5 vs. 44.6 for PP), and MAP (−2 log-likelihood difference 125.0 vs. 13.4 for PP) were stronger predictors of PO than PP.
Conclusion In CAD patients with hypertension, PP (on anti-hypertensive treatment) is a weaker predictor of cardiovascular outcomes than SBP, DBP, or MAP.
TL;DR: The present article will review the evidence collected throughout by years that an increase in the different markers of adrenergic drive, such as plasma norepinephrine and muscle sympathetic nerve traffic, characterizes this condition and reinforce the concept that drugs used in the metabolic syndrome should exert sympathoinhibitory effects.
TL;DR: To avoid a systematic misclassification of cardiovascular risk, LVM should be routinely indexed to height2.7 in overweight and obese patients representing a large percentage of the hypertensive population.
Abstract: Whether left ventricular mass (LVM) should be normalized to different indexes in relation to body size is still debated. We sought to evaluate the prevalence of left ventricular hypertrophy (LVH) defined by different indexation criteria in a cohort of hypertensive subjects categorized according to body mass index (BMI). A total of 2213 essential hypertensive subjects included in the Evaluation of Target Organ Damage in Hypertension (ETODH) were divided in three groups according to BMI thresholds ( or=30 kg m(-2)). All patients underwent extensive investigations including quantitative echocardiography. LVH was defined as an LVM index equal to or higher than (1) 125 g m(-2) in men and 110 g m(-2) in women, (2) 51 g m(-2.7) in men and 47 g m(-2.7) in women. Overall, 687 out of 2213 patients (31.0%) were found to have LVH when LVM was indexed to body surface area (BSA) and 1030 (46.5%) when indexed to height(2.7). A total of 845 patients (38.2%) had normal BMI, 954 patients (43.1%) were overweight and 414 (18.7%) were obese. Prevalence rates of LVH in the three groups were 25.1, 31.6, 41.2% by indexation to BSA and 29.9, 50.5, 71.8% by indexation to height(2.7), respectively. LVM indexed to BSA markedly underestimates LVH prevalence in obese as well as overweight hypertensive patients. To avoid a systematic misclassification of cardiovascular risk, LVM should be routinely indexed to height(2.7) in overweight and obese patients representing a large percentage of the hypertensive population.
The George Institute for Global Health1, University of Paris2, Utrecht University3, Icahn School of Medicine at Mount Sinai4, Monash University5, The Heart Research Institute6, University of Oxford7, Université de Montréal8, University of Melbourne9, University of Milan10, St Mary's Hospital11, University of Leicester12
TL;DR: SBP and PP are the 2 best and DBP is the least effective determinant of the risk of major cardiovascular outcomes in the relatively old patients with type 2 diabetes mellitus participating in the Action in Diabetes and Vascular Disease: Preterax and Diamicron-Modified Release Controlled Evaluation Study.
Abstract: The relative importance of various blood pressure indices on cardiovascular risk in people with type 2 diabetes mellitus has not been established. This study compares the strengths of the associations between different baseline blood pressure variables (systolic blood pressure [SBP], diastolic blood pressure [DBP], pulse pressure [PP], and mean arterial pressure) and the 4.3-year risk of major cardiovascular events in the Action in Diabetes and Vascular Disease: Preterax and Diamicron-Modified Release Controlled Evaluation Study. Mean (SD) age for the 11 140 participants was 65.8 years (6.4 years). During follow-up, 1000 major cardiovascular events, 559 major coronary events, and 468 cardiovascular deaths were recorded. After adjustment for age, sex, and treatment allocation, the hazard ratios (95% CIs) associated with 1 increment in SD for the risk of major cardiovascular events were 1.17 (1.10 to 1.24) for SBP; 1.20 (1.13 to 1.28) for PP; 1.12 (1.05 to 1.19) for mean arterial pressure; and 1.04 (0.98 to 1.11) for DBP. The areas under the receiver operating characteristic curve were slightly higher for SBP and PP compared with mean arterial pressure and DBP for major cardiovascular and coronary events. Using achieved instead of baseline blood pressure values marginally improved the effect estimates for SBP, DBP, and mean arterial pressure, with no significant differences in the areas under the receiver operating characteristic curve between models with SBP and those with PP. In conclusion, SBP and PP are the 2 best and DBP is the least effective determinant of the risk of major cardiovascular outcomes in the relatively old patients with type 2 diabetes mellitus participating in the Action in Diabetes and Vascular Disease: Preterax and Diamicron-Modified Release Controlled Evaluation Study. However, SBP may be the simplest and most useful predictor across a wider range of age groups and populations.
TL;DR: Factors commonly associated with and partly dependent on obesity, insulin resistance, such as overactivity of the sympathetic, stimulation of the renin–angiotensin–aldosterone systems, abnormal renal sodium handling, endothelial dysfunction, and large vessels' alterations, may play a key role in the blood pressure elevation of the syndrome.
Abstract: Arterial hypertension is often part of a constellation of anthropometric and metabolic abnormalities that occur simultaneously to a higher degree than would be expected by chance alone, supporting the existence of a discrete disorder, the so-called metabolic syndrome. It is the result of interactions among a large number of interconnected mechanisms, which eventually lead to both an increase in cardiovascular and renal risk, and the development of diabetes. Mechanisms involved in the metabolic syndrome are obesity, insulin resistance, and a constellation of independent factors, which include molecules of hepatic, vascular, and immunologic origin with pro-inflammatory properties. At each of these key points are interactions of demographics, lifestyle, genetic factors, and environmental fetal programming. Superimposing upon these are infections or chronic exposure or both to certain drugs that can also make their contribution. Skeletal muscle and the liver, not adipose tissue, are the two key insulin-response tissues involved in maintaining glucose balance, although abnormal insulin action in the adipocytes also plays a role in development of the syndrome. Factors commonly associated with and partly dependent on obesity, insulin resistance, such as overactivity of the sympathetic, stimulation of the renin-angiotensin-aldosterone systems, abnormal renal sodium handling, endothelial dysfunction, and large vessels' alterations, may play a key role in the blood pressure elevation of the syndrome.
TL;DR: It is concluded that their complex design precludes a simple interpretation, that several important questions remain unanswered and that direct evidence – particularly in support of lowering systolic BP below 140 or 130 mmHg – is urgently needed.
Abstract: A large body of clinical trial data indicates that a given difference in blood pressure (BP), as measured in the clinic, results in a given difference in outcome. This correlation underpins current US and European guidelines for the management of hypertension. However, findings from recent comparative trials may appear inconsistent with a fixed relationship between BP lowering and outcome benefit, at least at all BP ranges, at all levels of total cardiovascular risk and with all drug combinations. We review the findings of six of these recent trials and conclude that their complex design precludes a simple interpretation, that several important questions remain unanswered and that direct evidence - particularly in support of lowering systolic BP below 140 or 130 mmHg - is urgently needed.
TL;DR: Evidence is provided that retinal AVR is of limited value in identifying hypertensive patients at high cardiovascular risk related to cardiac and extracardiac organ damage, and left ventricular hypertrophy, carotid atherosclerosis and microalbuminuria in essential hypertension.
Abstract: AIM Whether retinal microvascular disease is associated with markers of cardiac and extracardiac organ damage in human hypertension is still unclear. We examined the relationship between retinal arteriolar-venular ratio (AVR) and left ventricular hypertrophy, carotid atherosclerosis and microalbuminuria in essential hypertension. METHODS A total of 386 untreated and treated uncomplicated essential hypertensive individuals (mean age 56 +/- 13 years) consecutively attending our hospital outpatient hypertension clinic were considered for the analysis. All individuals underwent extensive clinical and laboratory investigations, including retinal AVR evaluation by a fully automated computer-assisted method, echocardiography and carotid ultrasonography. RESULTS Mean retinal AVR was 0.790 +/- 0.079 (range 0.530-0.990). In univariate analyses, AVR showed a significant inverse association with left ventricular mass index (r = -0.15, P = 0.002) and carotid intima-media thickness (IMT) (r = -0.12, P = 0.02); no relationship with microalbuminuria was found. Overall, left ventricular mass index and carotid IMT as well as microalbuminuria, either as continuous or categorical variables, did not show significant differences across AVR quartiles. Moreover, a multivariate analysis failed to demonstrate independent correlations of carotid IMT and left ventricular mass index (P = 0.06 for both) with AVR. Finally, when patients were categorized according to the presence or absence of organ damage, with or without left ventricular hypertrophy (0.783 +/- 0.077 vs. 0.795 +/- 0.081), carotid plaques (0.789 +/- 0.079 vs. 0.791 +/- 0.079), carotid IMT (0.791 +/- 0.077 vs. 0.788 +/- 0.082) or microalbuminuria (0.791 +/- 0.080 vs. 0.777 +/- 0.073), no significant intergroup differences in AVR values were found. CONCLUSION Our findings provide further evidence that retinal AVR is of limited value in identifying hypertensive patients at high cardiovascular risk related to cardiac and extracardiac organ damage.
Journal Article•
TL;DR: Evidence will be presented that a maximum degree of sympathetic activation can be seen in end-stage renal failure, in which a relationship between sympathetic activation and clinical outcome has been documented, which has therapeutic implications, which involve the need to use treatments that oppose rather than enhance sympathetic neural activation.
Abstract: Given the importance of adrenergic neural functioning in cardiovascular control, the hypothesis that an elevation in sympathetic drive represents a key pathophysiological feature of diseases characterized by an impairment in cardiac or renal function has been long considered. However, modern approaches to directly quantify sympathetic nerve firing in humans have only been possible in the last 2 decades to provide objective documentation for the hypothesis. This paper will review the evidence that conditions such as essential hypertension, congestive heart failure and metabolic syndrome are all accompanied by an increased sympathetic drive, which is likely in all of them to play a pathogenetic role. It will then offer examples showing that sympathetic influences are directly involved in the progression of organ damage associated with these conditions. Finally, evidence will be presented that a maximum degree of sympathetic activation can be seen in end-stage renal failure, in which a relationship between sympathetic activation and clinical outcome has been documented. This has therapeutic implications, which involve the need to use treatments that oppose rather than enhance sympathetic neural activation.
TL;DR: Findings from INVEST support that BP reduction is important for prevention of adverse cardiovascular morbidity and mortality, and selection of antihypertensive agents should be based on patient comorbidities and other risk factors (e.g., risk for diabetes) and not necessarily that any one drug be given to all.
Abstract: The International Verapamil SR–Trandolapril Study (INVEST), a randomized trial of 22,576 predominantly elderly patients with an average 2.7-year follow-up, compared a calcium antagonist-led strategy (verapamil SR plus trandolapril) with a β-blocker-led strategy (atenolol plus hydrochlorothiazide) for hypertension treatment and prevention of cardiovascular outcomes in coronary artery disease patients. Patients received individualized dose and drug titration following a flexible, multi-drug, guideline-based treatment algorithm, with the objective of achieving optimal blood pressure (BP) control individualized for comorbidities (e.g., diabetes). The primary outcome (PO) was first occurrence of death (all-cause), nonfatal myocardial infarction or nonfatal stroke. The strategies resulted in significant and very similar BP reduction, with approximately 70% of patients in both strategies achieving BP control (<140/90 mmHg). Increasing number of office visits with BP in control was associated with reduced risk of...
TL;DR: It is indicated that the risk of MI is comparable with use of ARBs and other antihypertensive drugs in a wide range of clinical conditions.
Abstract: ObjectiveTo evaluate the effects of treatments based on angiotensin II receptor blockers (ARBs) on the risk of myocardial infarction (MI), cardiovascular and all-cause death, as compared with conventional treatment or placebo.MethodsWe performed a meta-analysis of all available major international,
TL;DR: The data indicate that a consistent portion of essential hypertensive patients are positive for LVH by the criterion of LVM indexed to height2.7, but not to BSA; this population is characterized by an unhealthy metabolic profile as well as by the presence of extracardiac organ damage.
Abstract: Aim Clinical abnormalities associated with left ventricular hypertrophy (LVH) only defined by left ventricular mass (LVM) indexed to height 2,7 are still undefined. We investigated the prevalence, clinical correlates and extracardiac organ damage of such a cardiac phenotype in essential hypertensive patients. Methods Subclinical organ damage was searched in 3719 untreated and treated hypertensive patients. LVH was defined by two sets of sex-specific criteria, namely, LVM indexed to height 2,7 (left ventricular mass index >49/45 g/m 2.7 in men and women, respectively) and LVM indexed to body surface area (BSA; left ventricular mass index >125/110 g/m 2 in men and women, respectively). Patients were categorized into three groups, according to the absence of LVH by both criteria (n=1912, group I), presence of LVH by the height 2.7 criterion only (n = 784, group II) and presence of LVH by both criteria (n = 997, group III). A fourth group (n = 26, <1 %), positive for LVH only by the BSA criterion, was excluded from the analysis as being too small. Results Group II included a higher number of female, obese patients and individuals with metabolic syndrome than the other groups. Moreover, in group II, absolute LVM values and the extent of extracardiac organ damage, as assessed by carotid intima-media thickness, carotid plaques, microalbuminuria and retinal changes were intermediate between group I and III. Conclusion Our data indicate that a consistent portion of essential hypertensive patients are positive for LVH by the criterion of LVM indexed to height 2.7 , but not to BSA; this population is characterized by an unhealthy metabolic profile as well as by the presence of extracardiac organ damage. They also suggest that, in order to improve cardiovascular stratification, LVM should be routinely indexed to both BSA and height 2.7 and patients categorized according to the consistency of both criteria.
TL;DR: In human hypertension, structural and functional cardiac changes induced by MS are not limited to the LV but also involve the right one, and structural cardiac alterations were more pronounced in hypertensive men and women with MS than in their non-MS counterparts.
Abstract: The metabolic syndrome (MS) is associated with structural and functional alterations of the left ventricle (LV); no evidence is available on the impact of the MS on the right ventricle (RV). To assess whether MS, as defined by the ATP III report, is associated with biventricular hypertrophy, a total of 286 hypertensive subjects (mean age 58.7±12.2 years) attending our outpatient clinic underwent the following procedures: (1) physical examination and standard clinic blood pressure (BP) measurement; (2) routine laboratory investigations; (3) M-mode, two-dimensional and Doppler echocardiography. LV hypertrophy (LVH) was defined by LM mass index X51/47 g m � 2.7 in men and women, respectively. Right-sided chambers were measured in parasternal long axis at the outflow tract and subcostal view; RV hypertrophy (RVH) was defined by anterior RV wall thickness X6.0/5.5 mm in men and women, respectively. Filling velocities of both ventricles were assessed by pulsed Doppler echocardiography. Structural cardiac alterations were more pronounced in hypertensive men and women with MS than in their nonMS counterparts and involved both ventricles as shown by the differences in continuous variables as well as in prevalence rates of LVH (58 and 48% vs 28 and 30%, respectively, Po0.01) and RVH (48 and 54% vs 25 and 35%, respectively, Po0.01). Both LV and RV filling in MS hypertensives were more dependent on the atrial systole. Our study shows that in human hypertension, structural and functional cardiac changes induced by MS are not limited to the LV but also involve the right one. Journal of Human Hypertension advance online publication, 18 September 2008; doi:10.1038/jhh.2008.119
TL;DR: RVH is commonly found in systemic hypertension and is associated with LVH (i.e., biventricular hypertrophy) in approximately one-fifth of the patients seen in a specialist setting, suggesting that this phenotype isassociated with a profile of very high cardiovascular risk.
Abstract: AimRight ventricular hypertrophy (RVH) has been reported to be a component of cardiac damage in systemic hypertension; this evidence, however, is based on small studies and major determinants of biventricular hypertrophy are still undefined. Thus, the prevalence and clinical correlates of RVH have b
TL;DR: Despite the universal health coverage of the Italian National Health Service (NHS), social disparities affect accessing and keeping antihypertensive therapy.
Abstract: We conducted this population-based cohort study by linking several databases to explore the role of socioeconomic position for accessing and keeping antihypertensive drug therapy. A total of 71 469 patients, residents in the city of Milan (Italy) aged 40–80 years, who received an antihypertensive drug during 1999–2002 were followed for 1 year starting from the first dispensation. Socioeconomic position and drug prescriptions were respectively obtained from tax registry and outpatient prescription database. The effect of socioeconomic characteristics on standardized incidence rate (SIR) of new users of antihypertensive agents, odds ratio (OR) of using combined antihypertensive agents and non-antihypertensive drugs and hazard ratio (HR) of discontinuing antihypertensive therapy were estimated after adjustment for potential confounders. SIRs were 3.7 and 4.2 per 1000 person-months among persons at the lowest and intermediate income, respectively, and 2.4 and 3.0 among immigrants and Italians, respectively. Compared to persons at the highest income, those at the lowest income had increased chances of starting with combined antihypertensive drugs (OR: 1.1; 95% confidence intervals (CIs): 1.0, 1.2), and of using drugs for heart failure (OR:1.5; CIs:1.3, 1.6) and diabetes (OR: 1.7; CIs: 1.6, 1.9). Compared with Italians, non-western immigrants had increased chances of starting with combined antihypertensive agents (OR: 1.2; CIs: 1.0, 1.3), of using drugs for heart failure (OR: 1.2; CIs: 1.0, 1.4) and for diabetes (OR: 1.8; CIs: 1.6, 2.1), and of interrupting antihypertensive therapy (HR: 1.1; 95% CIs: 1.0, 1.2). Despite the universal health coverage of the Italian National Health Service (NHS), social disparities affect accessing and keeping antihypertensive therapy.
TL;DR: These findings are concordant with the inference that epidemic obesity importantly influences epidemic occurrence of the other MetS traits and indicate that use of MetS for CVD risk assessment has limitations and needs critical reconsideration.