Showing papers by "Giuseppe Mancia published in 2010"

European Society of Hypertension Practice Guidelines for home blood pressure monitoring

Abstract: Self-monitoring of blood pressure by patients at home (home blood pressure monitoring (HBPM)) is being increasingly used in many countries and is well accepted by hypertensive patients. Current hypertension guidelines have endorsed the use of HBPM in clinical practice as a useful adjunct to conventional office measurements. Recently, a detailed consensus document on HBPM was published by the European Society of Hypertension Working Group on Blood Pressure Monitoring. However, in daily practice, briefer documents summarizing the essential recommendations are needed. It is also accepted that the successful implementation of clinical guidelines in routine patient care is dependent on their acceptance by involvement of practising physicians. The present document, which provides concise and updated guidelines on the use of HBPM for practising physicians, was therefore prepared by including the comments and feedback of general practitioners.

Genome-Wide Association Study of Blood Pressure Extremes Identifies Variant near UMOD Associated with Hypertension

Abstract: Hypertension is a heritable and major contributor to the global burden of disease. The sum of rare and common genetic variants robustly identified so far explain only 1%-2% of the population variation in BP and hypertension. This suggests the existence of more undiscovered common variants. We conducted a genome-wide association study in 1,621 hypertensive cases and 1,699 controls and follow-up validation analyses in 19,845 cases and 16,541 controls using an extreme case-control design. We identified a locus on chromosome 16 in the 59 region of Uromodulin (UMOD; rs13333226, combined P value of 3.6x10(-11)). The minor G allele is associated with a lower risk of hypertension (OR [95% CI]: 0.87 [0.84-0.91]), reduced urinary uromodulin excretion, better renal function; and each copy of the G allele is associated with a 7.7% reduction in risk of CVD events after adjusting for age, sex, BMI, and smoking status (H.R. = 0.923, 95% CI 0.860-0.991; p = 0.027). In a subset of 13,446 individuals with estimated glomerular filtration rate (eGFR) measurements, we show that rs13333226 is independently associated with hypertension (unadjusted for eGFR: 0.89 [0.83-0.96], p = 0.004; after eGFR adjustment: 0.89 [0.83-0.96], p = 0.003). In clinical functional studies, we also consistently show the minor G allele is associated with lower urinary uromodulin excretion. The exclusive expression of uromodulin in the thick portion of the ascending limb of Henle suggests a putative role of this variant in hypertension through an effect on sodium homeostasis. The newly discovered UMOD locus for hypertension has the potential to give new insights into the role of uromodulin in BP regulation and to identify novel drugable targets for reducing cardiovascular risk.

Reduced discontinuation of antihypertensive treatment by two-drug combination as first step. Evidence from daily life practice

Abstract: ObjectivesTo measure persistence with antihypertensive drug therapy in patients initiating treatment with mono or combination therapy.MethodsData analysis was based on two cohorts of patients, that is, a cohort derived from the registration of drug prescriptions in all residents of the Lombardy regi

Structural and functional alterations of subcutaneous small resistance arteries in severe human obesity.

Abstract: Obese persons are at increased cardiovascular risk and exhibit increased arterial stiffness and impaired endothelial function of large- and medium-size arteries. We hypothesized that normotensive subjects suffering from severe obesity would also present remodeling and endothelial dysfunction of small resistance arteries. A total of 16 lean (age: 49.6 +/- 2.9 years, BMI: 22.9 +/- 0.3 kg/m(2), mean +/- s.e.m.) and 17 age-matched severely obese (BMI: 41.1 +/- 2.3 kg/m(2)) normotensive subjects were investigated. None had glucose or lipid metabolic abnormalities except for insulin resistance. Resistance arteries, dissected from abdominal subcutaneous tissue, were assessed on a pressurized myograph. For superimposable blood pressure, the media thickness, media cross-sectional area (CSA), and media-to-lumen ratio values of resistance arteries were markedly and significantly greater in obese compared to lean subjects (media thickness 26.3 +/- 0.6 vs. 16.2 +/- 0.6 microm, CSA 22,272 +/- 1,339 vs. 15,183 +/- 1,186 microm(2), and media-to-lumen ratio 0.113 +/- 0.006 vs. 0.059 +/- 0.001, respectively, P < 0.01). Acetylcholine-induced relaxation was impaired in vessels from obese subjects compared to the lean individuals (-40.4 +/- 1.3%, P < 0.01), whereas endothelium-independent vasorelaxation was similar in all groups. Stiffness of small arteries as assessed by the stress/strain relationship was similar in lean and severely obese subjects. We conclude that severe human obesity is associated with profound alterations in structural and functional characteristics of small arteries, which may be responsible for the presence of elevated cardiovascular risk and increased incidence of coronary, cerebrovascular and renal events reported in obesity.

Results of a retrospective database analysis of adherence to statin therapy and risk of nonfatal ischemic heart disease in daily clinical practice in Italy.

Abstract: BackgroundThe use of a composite cardiovascular endpoint (CCEP) is frequent in clinical trials. However, the relation between the reduction in blood pressure (BP) and the risk of CCEP is poorly known.MethodsWe conducted a meta-analysis of trials, which compared different BP-lowering agents with plac

Influence of blood pressure reduction on composite cardiovascular endpoints in clinical trials.

Abstract: BackgroundThe use of a composite cardiovascular endpoint (CCEP) is frequent in clinical trials. However, the relation between the reduction in blood pressure (BP) and the risk of CCEP is poorly known.MethodsWe conducted a meta-analysis of trials, which compared different BP-lowering agents with plac

Effects of a fixed combination of perindopril and indapamide in patients with type 2 diabetes and chronic kidney disease

Abstract: Aims Individuals with diabetes and chronic kidney disease (CKD) are at high risk for cardiovascular disease. In these analyses of the ADVANCE trial, we assessed the effects of a fixed combination of perindopril–indapamide on renal and cardiovascular outcomes in patients with type 2 diabetes according to baseline CKD stage. Methods and results Patients with type 2 diabetes were randomized to perindopril–indapamide (4 mg/1.25 mg) or placebo. Treatment effects on cardiovascular (cardiovascular death, myocardial infarction, or stroke) and renal outcomes were compared in subgroups defined by baseline Kidney Disease Outcome Quality Initiative CKD stage. Homogeneity in treatment effect was tested by adding interaction terms to the relevant Cox models. The study included 10 640 participants with known CKD status, of whom 6125 did not have CKD, 2482 were classified as CKD stage 1 or 2, and 2033 as CKD stage ≥3. The relative treatment effects on major cardiovascular events were similar across all stages of CKD, with no heterogeneity in the magnitude of the effects for any outcome. In contrast, the absolute treatment effects approximately doubled in those with CKD stage ≥3 when compared to those with no CKD. For every 1000 patients with CKD stage ≥3 treated for 5 years, active treatment prevented 12 cardiovascular events when compared with six events per 1000 patients with no CKD. Conclusion The treatment benefits of a routine administration of a fixed combination of perindopril–indapamide to patients with type 2 diabetes on cardiovascular and renal outcomes, and death, are consistent across all stages of CKD at baseline. Absolute risk reductions are larger in patients with CKD highlighting the importance of blood pressure-lowering in this population.

Impact of different definitions of the metabolic syndrome on the prevalence of organ damage, cardiometabolic risk and cardiovascular events.

Abstract: ObjectivesWe compared definitions of metabolic syndrome performed by ATPIII [the National Cholesterol Education Program Adult Treatment Panel III; three criteria of the following: systolic blood pressure ≥130 mmHg and/or diastolic blood pressure ≥85 mmHg, fasting serum glucose ≥110 mg/dl, high-densi

Statins, antihypertensive treatment, and blood pressure control in clinic and over 24 hours: evidence from PHYLLIS randomised double blind trial

Abstract: Objective To investigate the possibility that statins reduce blood pressure as well as cholesterol concentrations through clinic and 24 hour ambulatory blood pressure monitoring. Design Randomised placebo controlled double blind trial. Setting 13 hospitals in Italy Participants 508 patients with mild hypertension and hypercholesterolaemia, aged 45 to 70 years. Intervention Participants were randomised to antihypertensive treatment (hydrochlorothiazide 25 mg once daily or fosinopril 20 mg once daily) with or without the addition of a statin (pravastatin 40 mg once daily). Main outcome measures Clinic and ambulatory blood pressure measured every year throughout an average 2.6 year treatment period. Results Both the group receiving antihypertensive treatment without pravastatin (n=254) (with little change in total cholesterol) and the group receiving antihypertensive treatment with pravastatin (n=253) (with marked and sustained reduction in total cholesterol and low density lipoprotein cholesterol) had a clear cut sustained reduction in clinic measured systolic and diastolic blood pressure as well as in 24 hour, and day and night, systolic and diastolic blood pressure. Pravastatin performed slightly worse than placebo, and between group differences did not exceed 1.9 (95% confidence interval −0.6 to 4.3, P=0.13) mm Hg throughout the treatment period. This was also the case when participants who remained on monotherapy with hydrochlorothiazide or fosinopril throughout the study were considered separately. Conclusions Administration of a statin in hypertensive patients in whom blood pressure is effectively reduced by concomitant antihypertensive treatment does not have an additional blood pressure lowering effect. Trial registration BRISQUI_*IV_2004_001 (registered at Osservatorio Nazionale sulla Sperimentazione Clinica dei Medicinali—National Monitoring Centre on Clinical Research with Medicines).

Effects of Intensive Blood Pressure Control in the Management of Patients With Type 2 Diabetes Mellitus in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial

Abstract: To appreciate the importance of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial,1 one needs to remember that the systolic blood pressure (BP) target currently recommended by major guidelines for diabetic patients, that is, 130 mm Hg, except in the Appropriate Blood Pressure Control in Diabetes Study (ABCD) normotensive trial,7 which consisted of only a few hundred patients and had changes in creatinine clearance as the primary end point. Thus, ACCORD represents the only large-scale randomized trial that provides information on what happens to the cardiovascular risk of diabetic patients when SBP is reduced to 130 mm Hg as a result of randomization to the usual (rather than the tight) BP control treatment strategy. Thus, the message from ACCORD to guidelines and clinical practice is that in diabetic patients it is not necessary to adopt …

Efficacy and safety of routine blood pressure lowering in older patients with diabetes: Results from the advance trial

Abstract: OBJECTIVE: The efficacy and safety of blood pressure lowering in elderly patients have not been sufficiently investigated in patients with diabetes. Using data from the Action in Diabetes and Vascular disease: preterAx and diamicroN-MR Controlled Evaluation study, we assessed the efficacy and safety of routine blood pressure lowering to prevent major clinical outcomes in elderly patients with type 2 diabetes. METHODS: Eleven thousand one hundred and forty patients aged at least 55 years with type 2 diabetes (mean 66+/-6 years) were randomly assigned to perindopril-indapamide or placebo. The primary endpoint was a composite of major macrovascular and microvascular disease. The effects of active treatment on outcomes were estimated in subgroups according to age: below 65, 65-74 and at least 75 years. RESULTS: During a mean 4.3-year follow-up, 1799 (16.1%) patients experienced a major event. Active treatment produced similar relative risk reductions for the primary outcome, major macrovascular disease, death and renal events across age groups (all P heterogeneity >0.3). Over 5 years, active treatment was estimated to prevent one primary outcome in every 21, 71 and 118 patients of at least 75, 65-74 and below 65 years, respectively. Similar patterns of benefits were observed for secondary outcomes. There were no differences in the tolerability between randomized allocations across age groups (all P heterogeneity >0.6) CONCLUSION: Routine administration of perindopril-indapamide lowers blood pressure safely and reduces the risk of major clinical outcomes in patients of at least 75 years with type 2 diabetes. The greater absolute benefits in older patients in this age group were not offset by an increased risk of side effects.

Evaluating 24-h antihypertensive efficacy by the smoothness index: a meta-analysis of an ambulatory blood pressure monitoring database.

Abstract: ObjectiveThe aim of this meta-analysis was to compare the 24-h antihypertensive efficacy of different treatments using the smoothness index.MethodsData were taken from the telmisartan ambulatory blood pressure monitoring (ABPM) clinical programme. Eleven clinical trials that randomized mild-to-moder

Reinforcement of the adrenergic overdrive in the metabolic syndrome complicated by obstructive sleep apnea.

Abstract: BACKGROUND Metabolic syndrome is characterized by a marked sympathetic overactivity. It is unknown, however, whether the neuroadrenergic activation can be ascribed to obstructive sleep apnoea (OSA), OSA exerts potentiating effects on the metabolic syndrome-related sympathetic activation and reflex/metabolic variables (insulin resistance) participate at the phenomenon. METHODS AND RESULTS We conducted a cross-sectional study of healthy individuals and metabolic syndrome patients recruited in our outpatient clinic. Fifty-five middle-age men classified according to Adult Treatment Panel III criteria and apnea-hypopnea index (overnight polysomnographic evaluation) as healthy controls without OSA and metabolic syndrome patients without and with OSA were studied. Blood pressure (Finapres), heart rate (ECG) and muscle sympathetic nerve activity (MSNA; microneurography) were measured at rest and during baroreflex manipulation. Compared with controls, patients with metabolic syndrome with and without OSA displayed higher waist-hip ratio, blood pressure, triglycerides and homeostasis model assessment index values but lower high-density lipoprotein cholesterol. MSNA was significantly higher in patients with metabolic syndrome without OSA than in controls (61.9 +/- 3.9 vs. 37.7 +/- 4.1 bursts/100 heartbeats, respectively, P < 0.01), a further marked increase being detected in patients with metabolic syndrome with OSA (77.1 +/- 4.3 bursts/100 heart beats, P < 0.01). Compared with controls, baroreflex control of heart rate and MSNA was markedly impaired in patients with metabolic syndrome with OSA, a further impairment in baroreflex-heart rate modulation being detected in metabolic syndrome with OSA. In the metabolic syndrome group as a whole, at the multivariate analysis, MSNA was significantly related to the apnoea-hypopnoea index but not to other variables. CONCLUSION Thus the sympathetic activation of metabolic syndrome occurs independently on OSA. OSA, however, markedly potentiates this neuroadrenergic abnormality via a hypoxic-dependent chemoreflex activation.

Effects of telmisartan and amlodipine in combination on ambulatory blood pressure in stages 1-2 hypertension.

Abstract: BackgroundEvaluation of combination therapy with antihypertensive agents by clinic blood pressure (BP) measurements may yield results that differ from out-of-office BP readings. This is of clinical relevance because out-of-office BP values are of prognostic importance. We studied the effects of comb

Office and 24-h ambulatory blood pressure control by treatment in general practice: the ‘Monitoraggio della pressione ARteriosa nella medicina TErritoriale’ study

Abstract: BackgroundGuidelines recommend that blood pressure (BP) should be lowered in hypertensive patients to prevent cardiovascular accidents. Management of antihypertensive treatment by general practitioners is usually based on office measurements, which may not allow an assessment of BP control over 24 h

The effects of sex and method of blood pressure measurement on genetic associations with blood pressure in the PAMELA study.

Abstract: BackgroundPhenotypic accuracy and specificity are essential for a successful genetic association study. Blood pressure (BP) measurements show heterogeneity depending on the method and time of measurement, sexual dimorphism and measurement errors, making genetic dissection difficult.Methods and resul

Impact of the metabolic syndrome on subcutaneous microcirculation in obese patients.

Abstract: OBJECTIVES Patients with the metabolic syndrome are at increased cardiovascular risk and display an augmented wall stiffness of the large-sized and medium-sized arteries, coupled with an endothelial dysfunction. Whether this is the case also for the small resistance arteries is unknown, however. It is also unknown whether and to what extent the hypothesized microvascular alterations are greater for magnitude than the ones characterizing obesity, that is the most common component of the metabolic syndrome. METHODS In 14 lean healthy controls (age 48.7 +/- 2.4 years, mean +/- SEM), 13 obese participants and 12 individuals with the metabolic syndrome (Adult Treatment Panel III criteria), all age-matched with healthy controls, we assessed the small resistance arteries dissected from the abdominal subcutaneous tissue on a pressurized myograph. RESULTS The media thickness, media cross-sectional area (CSA) and media-to-lumen ratio (M/L) of the small resistance arteries were markedly and significantly greater in metabolic syndrome than in controls (media thickness: 28.3 +/- 0.7 vs. 17.5 +/- 0.3 microm; CSA: 24 760.8 +/- 1459 vs. 16 170.7 +/- 843.6 microm and M/L: 0.12 +/- 0.01 vs. 0.064 +/- 0.002 a.u., respectively, P < 0.01 for all). Acetylcholine-induced relaxation was impaired in the vessels from metabolic syndrome participants compared with the lean healthy individuals (-48.8%, P < 0.01), whereas endothelium-independent vasorelaxation was similar in the two groups. The structural and functional microvascular alterations seen in metabolic syndrome were slightly, although not significantly, greater than the ones seen in uncomplicated obese participants. Stiffness of small arteries, as assessed by the stress/strain relationship, was also similar in the three groups of participants. CONCLUSION Thus, metabolic syndrome is characterized by marked alterations in the structural and functional patterns of the small resistance arteries. These alterations, which are only slightly greater than the ones seen in obesity, may be responsible for the increased incidence of coronary and cerebrovascular events reported in metabolic syndrome.

Time-weighted vs. conventional quantification of 24-h average systolic and diastolic ambulatory blood pressures

Abstract: BackgroundConventional calculation of mean 24-h ambulatory blood pressure (BP), SBP and DBP based on the average of all BP readings disregards the fact that a larger number of measurements is usually scheduled during the daytime than at night, an imbalance possibly leading to an overestimation of 24

Continuous positive airway pressure increases haemoglobin O2 saturation after acute but not prolonged altitude exposure.

Abstract: Aims It is unknown whether subclinical high-altitude pulmonary oedema reduces spontaneously after prolonged altitude exposure. Continuous positive airway pressure (CPAP) removes extravascular lung fluids and improves haemoglobin oxygen saturation in acute cardiogenic oedema. We evaluated the presence of pulmonary extravascular fluid increase by assessing CPAP effects on haemoglobin oxygen saturation under acute and prolonged altitude exposure. Methods and results We applied 7 cm H2O CPAP for 30 min to healthy individuals after acute (Capanna Margherita, CM, 4559 m, 2 days permanence, and <36 h hike) and prolonged altitude exposure (Mount Everest South Base Camp, MEBC, 5350 m, 10 days permanence, and 9 days hike). At CM, CPAP reduced heart rate and systolic pulmonary artery pressure while haemoglobin oxygen saturation increased from 80% (median), 78–81 (first to third quartiles), to 91%, 84–97 ( P < 0.001). After 10 days at MEBC, haemoglobin oxygen saturation spontaneously increased from 77% (74–82) to 86% (82–89) ( P < 0.001) while heart rate (from 79, 64–92, to 70, 54–81; P < 0.001) and respiratory rate (from 15, 13–17, to 13, 13–15; P < 0.001) decreased. Under such conditions, these parameters were not influenced by CPAP. Conclusion After ascent excessive lung fluids accumulate affecting haemoglobin oxygen saturation and, in these circumstances, CPAP is effective. Acclimatization implies spontaneous haemoglobin oxygen saturation increase and, after prolonged altitude exposure, CPAP is not associated with HbO2-sat increase suggesting a reduction in alveolar fluids.

Low anthracyclines doses-induced cardiotoxicity in acute lymphoblastic leukemia long-term female survivors

Abstract: Background High dosage anthracyclines in pediatric patients with acute lymphoblastic leukemia (ALL) is associated with cardiotoxicity. However, data on the cardiac effects of lower cumulative doses of these drugs are not conclusive. The aim of this study was to assess the cardiac effects of low cumulative anthracycline doses in long-term survivors of ALL. Procedure Echocardiograms were performed on 62 long-term ALL survivors, without any overt or sub-clinical signs or symptoms of heart failure. The interval after stopping therapy was 12.6 ± 4.3 years; the mean cumulative dose of anthracyclines was 228.2 ± 42.3 mg/m2. Left ventricular (LV) structure and function were studied by echocolor-Doppler. An age, gender and body surface area (BSA) matched group of healthy subjects was used as controls. Cardiac data were analyzed before and after BSA normalization. Results Long term survivors of ALL, showed a lower LV mass index, interventricular septal and posterior wall thickness, which were independently related to gender and to age at which the ALL diagnosis was made. Data analyzed according to gender showed that abnormalities were confined to the female group. No alterations were observed in the ALL male group versus the corresponding control group. No relationship was observed between the echocardiografic abnormalities and the duration of follow-up or the anthracycline mean dose employed. Conclusions In the absence of any signs or symptoms of heart failure, female ALL survivors treated with low cumulative anthracycline doses, showed a reduced LV mass and wall thickness. This suggests that in female ALL survivors an echocardyographic follow-up should be recommended. Pediatr Blood Cancer. 2010;55:1343–1347. © 2010 Wiley-Liss, Inc.

Manejo de la hipertensión arterial en niños y adolescentes: recomendaciones de la Sociedad Europea de Hipertensión

Abstract: Hypertension in children and adolescents has been gaining ground in cardiovascular medicine, mainly due to the advances made in several areas of pathophysiological and clinical research. These guidelines arose from the consensus reached by specialists in the detection and control of hypertension in children and adolescents. Furthermore, these guidelines are a compendium of scientific data and the extensive clinical experience it contains represents the most complete information that doctors, nurses and families should take into account when making decisions. These guidelines, which stress the importance of hypertension in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, should act as a stimulus for governments to develop a global effort for the early detection and suitable treatment of high pressure in children and adolescents. J Hypertens 27:1719-1742 Q 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

The "J curve" problem revisited: old and new findings.

Abstract: This paper critically addresses the issue of the “J-curve” paradox—the finding described in studies performed about 30 years ago indicating that treatment-induced systolic blood pressure values below 120 or 125 mm Hg and diastolic blood pressure values below 75 mm Hg are characterized by an increase, rather than a reduction, in the incidence of coronary events This paper focuses on four major subjects: 1) the benefits of a lower blood pressure target during treatment; 2) the historical background of the “J-curve” phenomenon; 3) the evidence collected in recent clinical trials regarding the existence of a “J-curve” in treated hypertensive patients; and 4) the recent recommendations by the Task Force Committee of the European Society of Hypertension on blood pressure goals to be achieved during treatment

Electrical Carotid Baroreceptor Stimulation in Resistant Hypertension

Abstract: Resistant hypertension, as identified when administration of a thiazide diuretic plus ≥2 other antihypertensive drugs, all at full doses, fails to control an elevated blood pressure, is by no means a minor clinical problem. According to recent publications,1 the number of individuals falling into this category is ≈15% to 20% of the overall hypertensive population. Given the high prevalence of hypertension, this translates into a figure of several million patients per major country and of more than a hundred million patients worldwide. Several therapeutic approaches have been proposed to enhance the size of blood pressure reduction in resistant hypertension and possibly to achieve, in a noticeable fraction, blood pressure control. One approach is to add to the existing multidrug regimen an antialdosterone agent,2 thereby more effectively blocking the sodium-retaining properties of this hormone, the release of which escapes to a significant degree the effect of the blockers of the renin-angiotensin system (angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists) presently available.3 Another approach is to complement the usual multipharmacological treatment strategy with the vasodilator influence of the antagonists of endothelin receptors, which, indeed, seems capable of adding a further blood pressure reduction to any previous therapeutic effect.4 A third approach is to resort to invasive procedures that can reduce the pressor or increase the depressor influences that physiologically modulate blood pressure. The invasiveness of this approach is ethically justified by the very high cardiovascular risk that characterizes the resistant hypertension condition.5 A reduction of the pressor influences can be obtained by denervating the kidneys through a radiofrequency generator positioned in the renal arteries through a percutaneously inserted catheter,6 because afferent fibers originating in the kidney exert sympathoexcitatory effects that can increase blood pressure,7 and removal of efferent sympathetic influences lowers overall total body norepinephrine …

Management of essential hypertension

Abstract: Introduction: Epidemiological studies have unequivocally shown that hypertension (HT)is a major cardiovascular (CV) risk factor and that a direct linear relationship exists between the severity of the blood pressure (BP) elevation and the occurrence of CV events. Areas of agreement and controversy: The beneficial effects of the BP-lowering interventions have been recognized since a number of years. These include not only the reduction in CV morbidity and mortality but also the regression (or the delay of progression) of HT-related end-organ damage, such as left ventricular hypertrophy, vascular remodelling, endothelial dysfunction and renal damage. Along with these well-established features, antihypertensive drug treatment still faces a number of unmet goals and unanswered questions, such as the target BP values to achieve in high-risk patients, the threshold of treatment in low-risk patients as well as the choice of the therapeutic approach more likely to offer greater CV protection.

Setting-up a blood pressure and vascular protection clinic: requirements of the European Society of Hypertension.

Abstract: IntroductionThe European Society of Hypertension (ESH) has certified ‘ESH Centres of Excellence’, which consist of teams of ESH hypertension specialists based on tertiary institutions/hospitals and are identified by their high quality expert scientific activity in research and clinical management, i

Increased pulse wave velocity and not reduced ejection fraction is associated with impaired baroreflex control of heart rate in congestive heart failure.

Abstract: BACKGROUND It is known that baroreflex sensitivity (BRS) is impaired in cardiac patients with myocardial infarction (MI). Nevertheless, it is unknown whether factors other than a reduced ejection fraction play a role in the baroreflex impairment of these patients. METHODS AND RESULTS Heart failure patients [congestive heart failure (CHF), n = 31, age 63 +/- 1.2 years, mean +/- SEM)], age-matched controls (n = 29) and coronary artery disease (CAD) patients without MI (n = 29) had RR interval and arterial blood pressure (BP) continuously monitored. Baroreflex function was assessed by the slope of the regression of RR interval, and BP responses to graded (-10, -20 and -40 mmHg) neck suction stimulation, the slope of bradycardic or tachycardic responses to spontaneous increases or reductions of SBP (sequence analysis) and the baroreflex efficiency index. Pulse wave velocity (PWV) was also measured.Compared with controls, CHF patients had RR interval and BP reflex responses to neck suction reduced by -36 and -54%, respectively (P < 0.01). By contrast, no differences were found between CHF and CAD patients. Similar reductions were observed for the sequence analysis (P < 0.01) in both CHF and CAD patients. Multiple regression analysis showed that in CHF and CAD patients, PWV and SBP and not ejection fraction were correlated with BRS. CONCLUSION The baroreflex function is impaired in CHF patients, the extent and the degree of baroreflex impairment being similar to that of CAD patients without MI. In CHF and CAD patients, the baroreflex impairment correlates significantly with the increased PWV and not with ejection fraction.

Left ventricular geometry, ambulatory blood pressure and extra-cardiac organ damage in untreated essential hypertension

Abstract: BACKGROUND AND AIM: Limited information is available on the association between left ventricular (LV) geometric patterns defined according to updated criteria and blood pressure (BP) levels and extra-cardiac organ damage (OD) in human hypertension. Thus, in untreated essential hypertensives we assessed the relationship between LV geometry, ambulatory BP and markers of vascular and renal OD. METHODS: A total of 669 hypertensives were categorized in four groups according to LV geometric patterns defined by two sets of sex-specific criteria (i.e. LV mass indexed to body surface area and height) and by the relative wall thickness (RWT) partition value of 0.42. Ambulatory BP variables were derived from two 24-h monitoring sessions performed within 4 weeks. RESULTS: Lower clinic and ambulatory BP values were associated with normal LV geometry, intermediate values with either LV concentric remodelling or eccentric LV hypertrophy (LVH) and higher values with concentric LVH, regardless of the criteria used to categorize these cardiac phenotypes. A decrease in nocturnal BP dip occurred from normal LV geometry to concentric LVH and this was associated with a parallel increase in the prevalence of carotid and renal OD, which was highest in concentric LVH. In a multivariate analysis age (beta=0.204, P<0.0001), followed by LDL cholesterol (beta=0.113, P=0.004), and night-time BP (beta=0.101, P=0.009) turned out to be the best independent correlates of RWT. CONCLUSION: These findings indicate that LV geometric patterns, regardless of categorization criteria, reflect different degrees of BP load and subclinical extra-cardiac alterations and may be regarded, in addition to absolute values of LV mass, as a reliable marker of cardiovascular (CV) risk.

Orthostatic hypotension and cardiovascular risk: defining the epidemiological and prognostic relevance.

Abstract: An extremely large amount of evidence documents without any doubt that a chronic elevation in blood pressure values represents at any age a major independent risk factor for cerebrovascular, coronary, and also renal disease.1–3 Evidence provided by a less consistent number of studies, however, has shown that also the opposite condition, i.e. a low blood pressure state, may indeed be associated with an increased cardiovascular risk. This is particularly the case for orthostatic hypotension, i.e. the clinical condition defined by international guidelines as that characterized by a blood pressure reduction during the first 3 min of assumption of the orthostatic position ≥20 mmHg for systolic and ≥10 mmHg for diastolic blood pressure, respectively.4,5 Indeed evidence has been provided that in patients with symptomatic and/or asymptomatic standing-related hypotension, without any evidence of co-existing conditions responsible for autonomic failure, the detection of this condition is associated with an increase in fatal and non-fatal cardiovascular events and also in all-cause mortality.6–8 The evidence, however, has been largely provided in elderly people, and there is much less information available in younger individuals.9,10 Fedorowsky and co-workers have reported the results of a prospective study,11 performed in the context of the Malmo Preventive Project, aimed at defining the prevalence, underlying causes, and prognostic value of orthostatic hypotension in a general Swedish population sample. The main features of the study can be summarized as follows.11 First, the study followed … *Corresponding author. Tel: +39 039 233 357, Fax: +39 039 322 274, Email: giuseppe.mancia{at}unimib.it

Baroreceptor sensitivity and baroreceptor effectiveness index in cirrhosis: the relevance of hepatic venous pressure gradient.

Abstract: Background: Autonomic dysfunction has been reported as one of the complications of cirrhosis. Aims: The aim of this study was to test autonomic dysfunction in cirrhotic patients by analysing the baroreflex sensitivity and the baroreceptor effectiveness index (BEI), in order to determine its correlation with the severity and the aetiology of liver disease. Moreover, we explored the relationship between baroreceptor function and mortality in our cohort of patients. Methods: Clinical and laboratory evaluation, hepatic venous pressure gradient (HVPG) and haemodynamic setting and baroreceptor function were assessed in 45 cirrhotic patients (median age 55, range 38–72 years) divided in groups according to the severity of their disease (26 patients Child A, 13 patients Child B and six patients Child C). Results: Baroreceptor sensitivity and BEI were impaired in more advanced cirrhotic patients compared with subjects with milder disease (P<0.001). HVPG was significantly, independently and inversely correlated with baroreceptor sensitivity (P=0.003). More severe impairment of baroreceptor function was associated with a higher mortality (P=0.04) and subjects with alcohol-related cirrhosis presented worse baroreceptor function (P=0.032) and poorer survival (P=0.003) compared with subjects with post-viral liver disease. Conclusions: These data support the hypothesis that liver disease severity and particularly portal hypertension have an important role in the derangement of baroreceptor function. The aetiology of cirrhosis seems to be related to baroreceptor impairment as well. Mortality rate is higher in subjects with a more damaged autonomic system, strengthening the idea of a worse prognosis in cirrhotic patients with autonomic neuropathy.