Metabolic syndrome score and ambulatory blood pressure in untreated essential hypertension.

BACKGROUND: The relationship between metabolic syndrome components, as defined by the Adult Treatment Panel III report, and ambulatory blood pressure in hypertensive patients has not been investigated to date. OBJECTIVE: To explore the relation between metabolic syndrome components ambulatory blood pressure levels and blood pressure day/night variations in a large population of never-treated essential hypertensive patients. METHODS: This investigation included 519 patients with uncomplicated grade 1 and 2 hypertension (mean age 45+11 years) who were attending a hypertension hospital outpatient clinic. They underwent the following procedures: (1) repeated clinic blood pressure measurements; (2) blood sampling for routine chemistry examinations; and (3) ambulatory blood pressure monitoring over two 24-h periods within 4 weeks. Because, by selection, all participants fulfilled one of the Adult Treatment Panel III criteria, the additional four criteria, abdominal obesity, hypertriglyceridemia, low HDL cholesterol and high blood fasting glucose, were specifically searched for. Patients were stratified according to the absence (group I) or the presence of one (group II), two (group III), three or four (group IV) components of the metabolic syndrome. Nocturnal dipping was defined as a night-time reduction in average systolic and diastolic blood pressure >10% compared to average daytime values. Each participant was classified according to the consistency of the dipping or nondipping status in the first and second ambulatory blood pressure measurement periods as follows: reproducible dipper (DD: decrease in blood pressure >10% in both ambulatory blood pressure measurement periods), reproducible nondipper (ND-ND: decrease in blood pressure <10% in both ambulatory blood pressure measurement periods) and variable dipper (VD: i.e dipper in one and nondipper in the other ambulatory blood pressure measurement period). RESULTS: In the whole population mean clinic and 48-h ambulatory blood pressures were 146/96 and 136/87 mmHg, respectively. In all, 197 patients (38%) had no metabolic syndrome components other than high blood pressure, 171 (33%) had one, 109 (21%) had two and 42 (8%) had three or four components. The four groups did not differ in age, clinic blood pressure, average 48-h, daytime, night-time systolic and diastolic blood pressure, and percentages of nocturnal fall in systolic and diastolic blood pressure. Furthermore, the distribution of three different ambulatory blood pressure patterns (DD, ND-ND and VD) was similar in the four groups: I=54.6%, 23.0%, 22.4%; II=51.1%, 21.7%, 27.2%; III=51.9%, 23.6%, 24.5%; and IV=52.7%, 27.2%, 25.1%, respectively. CONCLUSIONS: Our findings indicate that no significant relationship exists between the extent of metabolic alterations and ambulatory blood pressure levels or circadian variations in blood pressure in uncomplicated essential hypertensive patients.

Ambulatory blood pressure, target organ damage and left atrial size in never-treated essential hypertensive individuals.

OBJECTIVE: To investigate the relationship between ambulatory blood pressure and different markers of target organ damage with left atrial size in never-treated essential hypertensive individuals. METHODS: A total of 519 grade 1 and 2 hypertensive patients (mean age 46 +/- 12 years), referred for the first time to our outpatient clinic, underwent routine examinations: 24-h urine collection for microalbuminuria, ambulatory blood pressure monitoring over two 24-h periods in 4 weeks, echocardiography and carotid ultrasonography. RESULTS: Left atrial diameter was increased in 17.3% of patients. No significant differences were found between subjects with and without increased left atrial size with regard to sex, duration of hypertension, clinic and mean 48-h ambulatory blood pressure, and daytime and night-time values. Compared with 429 patients with normal left atrial size, the 90 patients with enlarged left atria were older, had higher body mass index, were more frequently smokers, and included more individuals with the metabolic syndrome. The prevalence of left ventricular hypertrophy, of intima-media thickening, but not of microalbuminuria was significantly higher in subjects with increased left atrial size. CONCLUSION: Left atrial enlargement is not an early echocardiographic finding in relatively young never-treated hypertensive individuals, as its prevalence is lower than that of well-validated markers of target organ damage, and it is unrelated to ambulatory blood pressure. Overweight, left ventricular hypertrophy, carotid intima-media thickening and metabolic syndrome are independent predictors of left atrial dimension, suggesting that changes in left atrial size represent an adaptive response when high blood pressure is associated with other cardiovascular or metabolic abnormalities.

Aortic coarctation suspected by Doppler echocardiography of renal arteries in hypertensive patients referred to a hospital outpatient hypertension clinic.

Coarctation of the aorta is the fourth most frequent form of congenital cardiovascular disease, which is diagnosed by the presence of higher blood pressures in the arms than in the legs. In this report we describe 3 cases of aortic coarctation, in which the correct diagnosis was suspected only months or years after the detection of hypertension, when a renal ultrasound examination was requested, despite the fact that the hallmarks of the disease were present at the physical examination in all patients. A marked reduction in renal flow velocities was suggestive of proximal aortic stenosis in all 3 cases. We conclude that the diagnosis of aortic coarctation, an uncommon but not so rare form of secondary hypertension, by renal ultrasonography rather than by a complete physical examination, reflects a commitment failure of physicians in everyday management of hypertension.

Prevalence and correlates of left atrial enlargement in essential hypertension: role of ventricular geometry and the metabolic syndrome: the Evaluation of Target Organ Damage in Hypertension study.

BACKGROUND: The cardiac effects of hypertension include a variety of structural changes such as increases in left ventricular mass (LVM) and left atrium (LA) size. Although data on hypertension-induced left ventricular changes are extensive, relatively little information is available on LA size from large-scale studies. OBJECTIVE: We sought to assess the prevalence of LA enlargement in a large selected hypertensive population and to determine the relations of LA size to several biologic variables including left ventricular hypertrophy (LVH) and metabolic disturbances. METHODS: A total of 2500 untreated and treated uncomplicated essential hypertensives consecutively attending, for the first time, our hospital out-patient hypertension clinic and included in the Evaluation of Target Organ Damage in Hypertension, an observational ongoing registry of hypertension-related target organ damage (TOD), were considered for this analysis. All patients underwent extensive clinical, laboratory and ultrasonographic investigations searching for cardiac (and extracardiac) TOD. The LA was considered enlarged when its anteroposterior diameter exceeded 3.7 cm in women and 4.1 cm in men. LVH was defined according to two different criteria: >/= 125 g/m in men and >/= 110 g/m in women; or >/= 51 g/m in men and >/=47 g/m in women. RESULTS: Enlarged LA diameter was present in 24.5% of women and in 21.5% of men. Compared with 1925 patients with normal LA size, the 575 patients with enlarged LA were older, more frequently overweight, had higher systolic blood pressure and included a greater proportion of subjects under antihypertensive treatment, with diabetes and metabolic syndrome. Both LA size and prevalence of LA enlargement differed significantly in relation to left ventricular geometry and LVM, being greater in patients with concentric or eccentric LVH than in those with left ventricular concentric remodeling or normal geometry. The prevalence of LA enlargement was similar in patients with concentric and eccentric LVH. According to a logistic regression analysis, overweight, LVH, fasting blood glucose > 7.0 mmol/l and metabolic syndrome were the main independent predictors of LA enlargement in the overall population as well as in both untreated and treated hypertensive subgroups. CONCLUSIONS: Our study suggests that: LA enlargement is a common echocardiographic finding in selected essential hypertensive patients with different left ventricular geometric patterns; LA size and LA enlargement is related to LVM rather than the type of LVH; and, in addition to LVH, overweight, high fasting glucose and metabolic syndrome are associated with LA dimensions.

Is the nocturnal fall in blood pressure reduced in essential hypertensive patients with metabolic syndrome?

OBJECTIVE: The aim of this study was to examine whether an impaired reduction in nocturnal blood pressure (BP), defined on the basis of two periods of ambulatory BP monitoring (ABPM), is present in hypertensive patients with metabolic syndrome, as defined by the NCEP criteria. METHODS: 460 grade 1 and 2 untreated essential hypertensives (mean age 45.9 +/- 11.9 years) referred for the first time to our outpatient hospital clinic underwent the following procedures: 1) medical history and physical examination; 2) repeated clinic BP measurements; 3) routine examinations; 4) ABPM over two 24-hour periods within 4 weeks. Metabolic syndrome was defined as at least three of the following alterations: increased waist circumference, increased triglycerides, decreased HDL-cholesterol, increased BP, or high fasting glucose. Nocturnal dipping was defined as a night-time reduction in average SBP and DBP >10% compared to average daytime values. RESULTS: The 135 patients with metabolic syndrome (group I) were similar for age, gender and known duration of hypertension to the 325 patients without it (group II). There were no significant differences between the two groups in average 48-hour, daytime, night-time SBP/DBP values and the percentage nocturnal SBP and DBP decrease (-17.7 / -15.7 vs. -18.4 / -16.2, p = ns). A reproducible nocturnal dipping (decrease in BP >10% from mean daytime in both ABPM periods) and non-dipping profile (decrease in BP < or =10% in both ABPM periods) was found in 74 (54.8%) and 29 (21.4%) in group I and in 169 (52.1%) and 73 (22.4%) in group II, respectively (p = ns); 32 patients (23.7%) in group I and 83 patients (25.5%) in group II had a variable dipping profile (p = ns). CONCLUSIONS: This study shows that no significant difference exists in nocturnal BP patterns, assessed by two ABPMs, in untreated essential hypertensive patients with metabolic syndrome compared to those without it.

Retinal microvascular changes and target organ damage in untreated essential hypertensives.

BACKGROUND AND PURPOSE: The clinical and prognostic significance of initial retinal alterations in hypertensive patients remains controversial. Therefore, we assessed the relationship of microvascular abnormalities with prognostically validated markers of target organ damage (TOD), such as left ventricular mass (LVM), carotid intima-media thickness (IMT) and microalbuminuria, in early stages of untreated essential hypertension. METHODS: A total of 437 consecutive, never-treated patients with grade 1 or 2 essential hypertension, referred to our outpatient clinic, underwent the following procedures: (1) clinical and routine laboratory examinations, (2) 24-h ambulatory blood pressure monitoring, (3) 24-h urine collection for microalbuminuria, (4) echocardiography, (5) carotid ultrasonography, (6) non-mydriatic retinography. Patients were divided into group I, with either a normal retinal pattern (n=65, 14.9%) or arteriolar narrowing (n=185, 42.4%) and group II with arteriovenous crossings (n=187, 42.7%). RESULTS: The two groups were similar for gender, body mass index, smoking habit, heart rate, clinic and ambulatory blood pressure (BP) values, while mean age was slightly but significantly higher in group II than in group I (47.6 +/- 10.7 versus 44.5 +/- 12.5 years, P=0.008). No differences occurred between the two groups in LVM index (101.8 +/- 18.5 versus 99.9 +/- 20.4 g/m), carotid IMT (0.67 +/- 0.12 versus 0.66 +/- 0.20 mm), urinary albumin excretion rate (14.4 +/- 27.7 versus 13.3 +/- 27.7 mg/24 h) as well as in the prevalence of LV hypertrophy (14.3 versus 14.0%), IM thickening and/or plaques (26.5 versus 27.2%) (both defined according to 2003 ESH-ESC guidelines) and microalbuminuria (10.1 versus 8.7%). Furthermore, the three different retinal artery patterns were similarly distributed among tertiles of LV mass index, IMT and urinary albumin excretion rate. CONCLUSIONS: These results show that: (1) a very large fraction (more than 80%) of untreated, recently diagnosed hypertensive patients have initial retinal microvascular abnormalities detectable by non-mydriatic retinography, (2) the presence of arteriovenous crossings is not associated with more prominent cardiac and extracardiac TOD, (3) fundoscopic examination has a limited clinical value to detect widespread organ involvement in early phases of grade 1 and 2 hypertension.

Metabolic syndrome and target organ damage in untreated essential hypertensives.

BACKGROUND: The prevalence and the relationship between metabolic syndrome, and target organ damage (TOD) in essential hypertensive patients has not been fully explored to date. OBJECTIVE: To investigate the association between metabolic syndrome, as defined by the ATP III report, and cardiac and extracardiac TOD, as defined by the 2003 ESH-ESC guidelines for management of hypertension, in a large population of never-treated essential hypertensives. METHODS: A total of 447 grade 1 and 2 hypertensive patients (mean age 46 +/- 12 years) who were attending a hypertension hospital outpatient clinic for the first time underwent the following procedures: (i) physical examination and repeated clinic blood pressure measurements; (ii) routine examinations; (iii) 24-h urine collection for microalbuminuria; (iv) 24-h ambulatory blood pressure monitoring; (v) echocardiography; and (vi) carotid ultrasonography. Metabolic syndrome was defined as involving at least three of the following alterations: increased waist circumference, increased triglycerides, decreased high-density lipoprotein cholesterol, increased blood pressure, or high fasting glucose. Left ventricular hypertrophy (LVH) was defined according to two different criteria: (i) 125 g/m in men and 110 g/m in women; (ii) 51 g/h in men and 47 g/h in women. RESULTS: The 135 patients with metabolic syndrome (group I) were similar for age, sex distribution, known duration of hypertension and average 24-h, daytime and night-time ambulatory blood pressure to the 312 patients without it (group II). The prevalence of altered left ventricular patterns (LVH and left ventricular concentric remodelling) was significantly higher in group I (criterion a = 30%, criterion b = 42%) than in group II (criterion a = 23%, criterion b = 30%, P < 0.05 and P < 0.01, respectively). A greater urinary albumin excretion (17 +/- 35 versus 11 +/- 23 mg/24 h, P = 0.04) was also found in group I compared to group II. There were no significant differences between the two groups in the prevalence of carotid intima-media thickening and plaques. CONCLUSIONS: These results from a representative sample of untreated middle-aged hypertensives show that: (i) the metabolic syndrome is highly prevalent in this setting and (ii) despite similar ambulatory blood pressure values, patients with metabolic syndrome have a more pronounced cardiac and extracardiac involvement than those without it.

Cardiovascular risk stratification according to the 2003 ESH-ESC guidelines in uncomplicated patients with essential hypertension: comparison with the 1999 WHO/ISH guidelines criteria.

BACKGROUND: The 2003 European Society of Hypertension/European Society of Cardiology (ESH-ESC) guidelines have recently proposed a new risk stratification scheme for estimating absolute risk for cardiovascular disease. At variance from the previous 1999 World Health Organization-International Society of Hypertension (WHO/ISH) guidelines, the new criteria include some additional risk factors such as obesity, abnormal high-density (HDL) or low-density lipoprotein (LDL) cholesterol levels and define a slight increase in creatinine and microalbuminuria as signs of target organ damage (TOD). OBJECTIVE: The aim of the study was to assess overall cardiovascular risk in uncomplicated hypertensives according to the 2003 ESH-ESC guidelines comparing this approach with the stratification scheme of the 1999 WHO/ISH guidelines. METHODS: Four hundred and twenty-five never-treated grade 1 and 2 essential hypertensive patients, referred for the first time to our outpatient clinic without diabetes mellitus, were included in the study. They underwent the following procedures: (i) repeated clinical blood pressure measurements; (ii) routine blood chemistry and urine analysis; (iii) electrocardiogram; (iv) 24-h urine collection for microalbuminuria; (v) echocardiogram; and (vi) carotid ultrasonogram. Risk was assessed according to both stratification schemes suggested by the 2003 ESH-ESC and 1999 WHO/ISH guidelines. RESULTS: According to the 2003 ESH-ESC guidelines, 15.5% of the 425 patients were considered at low added risk, 47.8% at medium added risk and 36.7% at high added risk; 146 patients (34.3%) were classified in the high-risk stratum because of at least one manifestation of TOD and 5.6% having three or more risk factors. The accuracy in detecting TOD of the combined approach with ultrasound procedures and microalbuminuria was approximately 10-fold higher than that provided by routine investigation. As a result of the 1999 WHO/ISH stratification scheme, 34.5% were low-risk, 34.4% medium-risk and 31.1% high-risk patients. CONCLUSIONS: Our findings show that: (i) more than one-third of uncomplicated grade 1 and 2 hypertensives seen in a outpatient hypertension hospital clinic have a high added risk according to the ESH-ESC scheme; (ii) classification of the patients in the high stratum is mainly influenced by the presence of TOD; (iii) the routine diagnostic work-up is a highly insensitive approach for the detection of TOD; (iv) the 2003 ESH-ESC guidelines stratify a higher proportion of hypertensive patients in the medium and high-risk groups than do the 1999 WHO/ISH guidelines.

High prevalence of retinal vascular changes in never-treated essential hypertensives: an inter- and intra-observer reproducibility study with non-mydriatic retinography.

BACKGROUND: The clinical significance of stratifying cardiovascular risk in hypertensive patients on the basis of retinal changes such as arteriolar narrowing or arterio-venous crossing has been criticized. AIM: Objectives of the study were: (i) to compare the prevalence of retinal abnormalities detected by non-mydriatic retinography with that of other quantitative markers of target organ damage (TOD), such as echocardiographically determined left ventricular hypertrophy (LVH), carotid structural abnormalities and microalbuminuria in recently diagnosed and never treated hypertensives; (ii) to assess the inter- and intra-observer reproducibility in evaluating retinal microvascular changes. METHODS: One hundred ninety-seven grade 1 (73%) and grade 2 essential hypertensives (119 males; mean age 46.8 +/- 12.0 years, duration of hypertension: 2.3 +/- 1.8 years) referred for the first time to our outpatient hypertension hospital clinic were subjected to the following procedures: (i) repeated clinic blood pressure (BP) measurements; (ii) electrocardiogram; (iii) routine blood chemistry and urinalysis; (iv) 24-h urine collection for microalbuminuria; (v) 24-h ambulatory BP monitoring; (vi) non-mydriatic retinography; (vii) echocardiogram; (viii) carotid ultrasonography. Retinal changes were evaluated according to a modified Keith, Wagener and Barker (KWB) classification by two physicians, who had no knowledge of the patients' characteristics. These following markers of TOD were considered: (i) left ventricular mass index > or = 125 g/m2 in men and > or = 110 g/m2 in women; (ii) at least one carotid plaque (focal thickening > 1.3 mm) or diffuse common carotid thickening (> or = 0.9 mm); (iii) microalbuminuria (urinary albumin excretion > or = 30 and < 300 mg/24 h). RESULTS: The prevalence rates of LVH, carotid structural alterations and microalbuminuria were 12.9, 26.0 and 8.6% respectively; while the distribution of patients in the different degrees of hypertensive retinopathy made by two independent readers (1 and 2) was: 0 = 15.2, I = 25.4, II = 58.9, III = 0.5% (1); 0 = 14.7, I = 27.9, II = 56.8, III = 0.5% (2), p = NS. The overall prevalence of retinal changes was 84.3% and 84.7%, respectively, and the inter- and intra-observer reproducibility 89.1, 91.6 (1) and 90.2% (2), respectively. CONCLUSIONS: Our data indicate that: (i) the prevalence of initial retinal changes is far higher than that of other prognostically validated quantitative markers of cardiac and extracardiac TOD; (ii) the inter- and intra-observer reproducibility between two skilled readers in detecting these abnormalities with non-mydriatic retinography is excellent; (iii) the high prevalence of retinal changes in untreated subjects with mild hypertension offers a new piece of evidence that they cannot be considered a proof of TOD.