Altered circadian blood pressure profile and prognosis.

BACKGROUND: In a previous analysis of the Progetto Ipertensione Umbria Monitoraggio Ambulatoriale we found a higher rate of cardiovascular morbid events among hypertensive nondippers than we did among dippers (5.86 versus 1.18 events per 100 person-years, P = 0.0002) for women, whereas the difference between the two groups was smaller and not statistically significant for men (4.15 versus 2.48 events per 100 person-years). These differences held in a multivariate analysis after adjustment for several confounders including average 24 h ambulatory blood pressure. In another analysis, the rate of occurrence of cardiovascular end-points was higher among nondippers than it was among dippers regardless of the definition of day and night (0600-2200 h and 2200-0600 h, awake and asleep, and 1000-2000 h and 2400-0600 h) and of the dividing line between dippers and nondippers (10 versus 0% day-night difference in blood pressure). OBJECTIVE: To test in a subsequent analysis based on a larger sample and a longer follow-up period, for both sexes, the prognostic value of a blunted diurnal rhythm of blood pressure. METHOD: We used the night: day ratio of ambulatory blood pressure, a continuous and normally distributed variable. RESULTS: A night: day systolic blood pressure ratio > 0.899 for men and > 0.909 for women (upper tertiles of distributions) identified a subset of subjects with greater than normal cardiovascular risk for any level of concomitant risk factors, wherease the hight:day diastolic blood pressure ratio was not statistically significant as an independent predictor. The excess risk for subjects in the upper tertile of the night: day systolic blood pressure ratio held after adjustment for several risk markers, including average 24 h ambulatory blood pressure. CONCLUSION: These data suggest that a blunted reduction in blood pressure from day to night predicts an increased cardiovascular morbidity at any level of concomitant risk factors including average 24 h ambulatory blood pressure. Nondippers can be defined in terms of a night: day ambulatory systolic blood pressure ratio > 0.899 for men and > 0.909 for women, regardless of the diastolic blood pressure profile.

Identification of subjects with white-coat hypertension and persistently normal ambulatory blood pressure.

OBJECTIVE: To assess the spontaneous changes in clinic blood pressure, ambulatory blood pressure (ABP) and left ventricular structure in untreated subjects with white-coat hypertension (WCH). DESIGN: A prospective observational study. PATIENTS AND METHODS: In 83 untreated subjects with WCH, 24 h non-invasive ABP monitoring and echocardiographic studies of the left ventricle were repeated after 0.5-6.5 years (mean 2.5) in the absence of antihypertensive drug treatment. WCH was defined by an average daytime ABP < 131/86 mmHg in women and < 136/87 mmHg in men. Ambulatory hypertension was defined by higher ABP values. RESULTS: In the whole population, the clinic blood pressure, ABP and left ventricular mass did not change from baseline to the follow-up visit, whereas the peak A: peak E ratio (where A is the velocity of transmitral blood flow after atrial contraction and E is the velocity during passive left ventricle filling) increased from 0.86 to 0.93. Sixty-three per cent of subjects remained in the WCH category at follow-up study; the remaining 37% shifted to the ambulatory hypertension category. The former group showed no changes in clinic blood pressure, ABP, left ventricular mass and peak A: peak E ratio. The clinic blood pressure of those who developed ambulatory hypertension did not change, whereas their ABP and peak A: peak E ratio increased and their left ventricular mass increased slightly but not significantly. The left ventricular mass increased from baseline to follow-up study by 6.2% in those who developed ambulatory hypertension and decreased by 1.6% in those who remained in the WCH category. The changes in left ventricular mass were associated with the changes in average 24 h systolic blood pressure, but not with the changes in clinic blood pressure. In a stepwise logistic regression analysis, average daytime diastolic blood pressure was the sole variable to enter the model and the probability of ambulatory hypertension at follow-up study was 20.0%percnt; in those with basal daytime ABP <130/80 mmHg, versus 81% in those with higher basal daytime blood pressure levels. CONCLUSION: After 0.5-6.5 years, WCH spontaneously evolved into ambulatory hypertension in 37% of subjects, with an accompanying rise in left ventricular mass. The probability of ambulatory hypertension increased with the baseline values of ABP, rather than with those of clinic blood pressure. WCH might be a prehypertensive state (particularly in subjects with higher baseline ABP levels) and should be defined by low levels of daytime ABP, possibly lower than 130/80 mmHg.

Gender, day-night blood pressure changes, and left ventricular mass in essential hypertension. Dippers and peakers.

The finding of increased left ventricular (LV) mass in hypertensive subjects with blunted nocturnal fall in blood pressure (BP) might be an artifact of matching patients for daytime BP, with resulting higher 24-h BP in nondippers. Therefore, we compared a large number (n = 1048) of hypertensive dippers and nondippers in their LV mass at echocardiography before and after adjustment for 24-h, daytime, and nighttime ambulatory BP. In men, the difference between dippers and nondippers was not significant before and after adjustment for 24-h BP, but after adjustment for nighttime BP LV mass was greater in dippers (more properly "peakers"). In women, LV mass was greater in nondippers than in dippers both before and after adjustment for 24-h BP, while the difference between the two groups disappeared after adjustment for nighttime BP. Thus, for any given level of mean 24-h BP, a flattened diurnal BP profile is associated with a greater LV mass in hypertensive women. Daytime hypertension, either associated or not with a blunted nocturnal fall in BP, may be a sufficient determinant of LV wall thickening in men.

[The irrelevance of the clinical arterial pressure with respect to outpatient pressure in defining the risk of left ventricular hypertrophy in essential arterial hypertension]. / Irrilevanza della pressione arteriosa clinica, rispetto a quella ambulatoriale, nella definizione del rischio di ipertrofia ventricolare sinistra nell'ipertensione arteriosa essenziale.

To investigate whether the level of clinical blood pressure (BP) may serve to stratify the risk of left ventricular (LV) hypertrophy in essential hypertension regardless of the level of ambulatory BP, we performed 24-hour noninvasive ambulatory BP monitoring and echocardiography in 115 consecutive hypertensive patients who had never been treated before and in 92 normotensive subjects. Hypertensive patients were grouped according to the difference between the observed clinical BP and the predicted value of clinical BP, defined by regressing the observed clinical BP on the 24-hour average of the ambulatory BP: "low" clinical BP group (clinical systolic BP less than = 10 mmHg, diastolic BP less than = 6 mmHg than predicted values), "high" clinical BP group (systolic greater than = 10 mmHg, diastolic greater than = 6 mmHg than predicted values), "intermediate" clinical BP group (values within the above mentioned limits). Ambulatory BP did not show any statistically significant differences between the three groups. LV mass index was higher in hypertensive patients in each of the three groups (including the "low" clinical BP group) as compared with the normotensive group (all p less than 0.01), but did not show any statistically significant difference among the three groups of hypertensive patients, either defined by systolic BP or by diastolic BP. Other indexes of LV anatomy (relative wall thickness, cross-sectional area) showed a similar pattern.(ABSTRACT TRUNCATED AT 250 WORDS)

[Anemia in primary hyperparathyroidism. Description of 2 case]. / Anemia nell'iperparatiroidismo primario. Descrizione di due casi.

Two cases of hyporigenerative anaemia in primary hyperparathyroidism are reported. The absence of other causes of anaemia and the correction of hematological disorder after parathyroidectomy, indicates that PTH hypersecretion is responsible for anaemia. The relationships between calcium levels controlling mechanisms and erithropoiesis are discussed.

[A case of polyarteritis nodosa associated with pulmonary hypertension].

A case of polyarteritis nodosa marked by concomitant systemic and pulmonary hypertension is presented. The part played by pulmonary hypertension in this disease is briefly discussed in the light of the necropsy findings and the literature.

[Correlations between hemodynamic parameters and "a" wave in the right apicocardiogram in patients with arterial pulmonary hypertension (author's transl)]. / Correlazioni tra parametri emodinamici e onda "A" nell'apicocardiogramma destro in pazienti con ipertensione arteriosa polmonare

In a group of patients with arterial pulmonary hypertension of various origin, the relationship between the relative magnitude of the "a" wave of the right apex-cardiogram (ACG) to the total deflection of the ACG ("a/H ratio") to both the right atrial "a" wave and the right ventricular end-diastolic pressure was studied. Both correlations were statistically significant. The results obtained confirm the ACG value in the non invasive study of the right ventricular function.