Long-term prognostic value of white coat hypertension: an insight from diagnostic use of both ambulatory and home blood pressure measurements.

The prognostic value of white coat hypertension (WCH) is still debated. In 2051 subjects representative of the general population of Monza, we measured office, ambulatory, and home blood pressure (BP). The risk of cardiovascular and all-cause mortality was assessed over 16 years in normotensive, sustained hypertensive, and WCH subjects, the last group being defined as usually done in clinical practice (ie, by normality of 1 out-of-office [ambulatory or home] BP with an office BP elevation). Compared with normotensive subjects, the risk of cardiovascular mortality, as adjusted for potential confounders, showed a progressive significant increase in WCH and sustained hypertensive subjects (2.04 and 2.94; P=0.006). In either group, a significant increase in adjusted risk was also seen for all-cause mortality. However, when the WCH group was subdivided into 2 subgroups, that is, subjects in whom both out-of-office BPs were normal (true WCH, 42%) or one BP was normal whereas the other was elevated (partial WCH, 58%), only the latter showed a significantly greater adjusted risk of cardiovascular and all-cause mortality (2.76 and 1.58; P<0.03). Compared with normotensive subjects, the partial WCH group also exhibited a marked increase in adjusted risk of developing sustained hypertension over a 10-year time period (2.58; P<0.0001), but in this case the risk was also increased in true WCH subjects (2.89; P<0.0001). Thus, WCH includes subjects with a widely different long-term risk of a cardiovascular event. To identify those at higher risk, measurements of both out-of-office BPs are desirable.

The Pamela study: main findings and perspectives.

PAMELA (Pressioni Arteriose Monitorate E Loro Associazioni) is an epidemiological study, originally designed to determine the normality of home and ambulatory blood pressure values. The study was performed on 3,200 subjects, aged 25 to 74 years, randomly selected from the general population of Monza (Milan, Italy). In the study context we performed clinical, home and ambulatory blood pressure measurements, echocardiographic assessment of cardiac structure and function as well as laboratory examinations (glucose and lipids). Personal and family histories were collected. The same procedures were repeated 10 years later. During a 12-year follow-up, the incident cardiovascular events were validated. Cardiovascular and all-cause fatal events were collected for a 16-year follow-up. This article will review the main results of the PAMELA study, with particular emphasis on (1) the prognostic value of the different blood pressure measurements, (2) the relationships between metabolic variables and blood pressure and (3) the clinical relevance and prognostic importance of left ventricular mass values and alterations.

Normal values of left-ventricular mass: echocardiographic findings from the PAMELA study.

BACKGROUND AND AIM: Upper reference values of echocardiographic left-ventricular mass in the European population are based on scanty data mostly derived from northern European population-based samples. Furthermore, data in apparently healthy populations have included individuals with conditions affecting left-ventricular mass such as obesity, diabetes and masked hypertension. Thus, from 1051 individuals with normal office blood pressure (BP) belonging to the PAMELA (Pressioni Arteriose Monitorate E Loro Associazioni) study population, we selected a group of 675 sustained normotensive individuals in order to provide reliable echocardiographic reference values for defining the criteria of left-ventricular hypertrophy (LVH). METHODS: The study group (women 58%, mean age 42 ±â€Š11 years) was identified after excluding individuals with isolated home or ambulatory hypertension, obesity, diabetes, cardiovascular diseases and echocardiographic examinations of insufficient quality to evaluate left-ventricular mass. RESULTS: Sex-specific upper limits of normality [mean + 1.96 standard deviation (SD)] for left-ventricular mass, left-ventricular mass indexed to body surface area, heightand height were the following: 213 g, 114 g/m, 51 g/h, 123 g/h in men and 161 g, 99  g/m, 47 g/h, 101 g/h in women. In multivariate analyses, body size measures and ambulatory BP levels were the most important correlates of left-ventricular mass. CONCLUSIONS: Our investigation by providing upper reference limits of left-ventricular mass in a southern European population sample, carefully selected after exclusion of a large number of conditions affecting left-ventricular mass, may offer a contribution for revising diagnostic criteria of echocardiographic LVH currently recommended by European hypertension guidelines.

Impact of body mass index and waist circumference on the long-term risk of diabetes mellitus, hypertension, and cardiac organ damage.

Obesity is associated with a higher risk of developing diabetes mellitus (DM), hypertension (HT), and left ventricular hypertrophy (LVH). The present study assessed in the general population the impact of body weight and visceral obesity on the development of alterations in glucose metabolism and cardiac structure, as well as of elevation in blood pressure. In 1412 subjects randomly selected and representative of the general population of Monza, we assessed twice (in 1990/1991 and 2000/2001) body mass index (BMI); waist circumference; office, home, and 24-hour ambulatory (24-hour) blood pressure, fasting glycemia, and left ventricular mass (echocardiography). New-onset high-risk conditions were DM; impaired fasting glucose; office, home, and 24-hour HT; and LVH. The incidence of new-onset DM; impaired fasting glucose; office, home, and 24-hour HT; and LVH increased progressively from the quintile with the lowest to the quintile with the highest BMI values. Adjusting for confounders, the risk of developing new-onset DM; impaired fasting glucose; office, home, and 24-hour HT; and LVH increased significantly for an increase of 1 kg/m(2) of BMI and 1 cm of waist circumference (respectively, 8.4% [P<0.01], 9.5% [P<0.0001], 4.2% [P<0.0001], 3.9% [P<0.001], 2.5% [P<0.05], and 5.1% [P<0.001] for BMI and 3.2% [P<0.001], 3.5% [P<0.0001], 1.8% [P<0.0001], 1.5% [P<0.0001], 1.4% [P<0.001], and 2.6% [P<0.0001]). These data provide evidence that an increase in BMI and waist circumference is associated with a linearly increased adjusted risk of developing conditions with high cardiovascular risk, such as DM, impaired fasting glucose, in- and out-of-office HT, and LVH.

Evaluation of how gene-job strain interaction affects blood pressure in the PAMELA study.

OBJECTIVE: To see whether there is interaction between single nucleotide polymorphisms (SNPs) belonging to candidate genes for hypertension and job strain and its components (job demand and job control) in an accurately phenotyped Italian cohort (Pressioni Arteriose Monitorate E Loro Associazioni). METHODS: From the Pressioni Arteriose Monitorate E Loro Associazioni cohort, we sampled 924 employed men and women who had completed a modified version of the Karasek questionnaire and for whom deoxyribonucleic acid information was available. We selected 1,510 common tagging and putative functional SNPs in 92 candidate autosomal genes involved in sympathetic nervous system, oxidative stress, renin-angiotensin-aldosterone system, and sodium balance. The interaction of each candidate SNP with the perceived job stress scores on ambulatory systolic and diastolic blood pressures was evaluated by adding product terms to a multiple regression linear model, adjusted for sex, age, total cholesterol, and body mass index. RESULTS: Among all the SNPs tested, the interaction of SNP rs11210278 located on the endothelin 2 gene and job control was statistically significant after controlling for multiple testing, using false discovery rate (unadjusted p = .00000661; p adjusted for false discovery rate = .0085), indicating an inverse association with systolic blood pressure for the homozygous wild-type allele (C/C) and a positive association for the variant genotypes (C/T and T/T). CONCLUSIONS: We show that the hypertensive response to job strain is present only in carriers of the rs11210278 wild-type genotype. The phenomenon is discussed in relationship to the controversial results of field studies on job strain and hypertension.

The contribution of major risk factors and job strain to occupational class differences in coronary heart disease incidence: the MONICA Brianza and PAMELA population-based cohorts.

OBJECTIVES: We investigated the contribution of major coronary heart disease (CHD) risk factors and job strain to occupational class differences in CHD incidence in a pooled-cohort prospective study in northern Italy. METHODS: 2964 men aged 25-74 from four northern Italian population-based cohorts were investigated at baseline and followed for first fatal or non-fatal CHD event (171 events). Standardised procedures were used for baseline risk factor measurements, follow-up and validation of CHD events. Four occupational classes were derived from the Erikson-Goldthorpe-Portocarero social class scheme: higher and lower professionals and administrators, non-manual workers, skilled and unskilled manual workers, and the self-employed. HRs were estimated with Cox models. RESULTS: Among CHD-free subjects, with non-manual workers as the reference group, age-adjusted excess risks were found for professionals and administrators (+84%, p=0.02), the self-employed (+72%, p=0.04) and manual workers (+63%, p=0.04). The relationship was consistent across different CHD diagnostic categories. Adjusting for major risk factors only slightly reduced the reported excess risks. In a sub-sample of currently employed subjects, adjusting for major risk factors, sport physical activity and job strain reduced the excess risk for manual workers (relative change = -71.4%) but did not substantially modify the excess risks of professionals and administrators and the self-employed. CONCLUSIONS: In our study, we found higher CHD incidence rates for manual workers, professionals and administrators, and the self-employed, compared to non-manual workers. When the entire spectrum of job categories is considered, the job strain model helped explain the CHD excess risk for manual workers but not for other occupational classes.

Gender differences in the association between education and the incidence of cardiovascular events in Northern Italy.

BACKGROUND: The educational differences in the incidence of major cardiovascular events are under-studied in Southern Europe and among women. METHODS: The study sample includes n = 5084 participants to 4 population-based Northern Italian cohorts, aged 35-74 at baseline and with no previous cardiovascular events. The follow-up to ascertain the first onset of coronary heart disease (CHD) or ischaemic stroke ended in 2002. At baseline, major cardiovascular risk factors were investigated adopting the standardized MONICA procedures. Two educational classes were obtained from years of schooling. Age- and risk factors-adjusted hazard ratios of first CHD or ischaemic stroke were estimated through sex-specific separate Cox models (high education as reference). RESULTS: Median follow-up time was 12 years. Event rates were 6.38 (CHD) and 2.12 (ischaemic stroke) per 1000 person-years in men; and 1.59 and 0.94 in women. In men, low education was associated with higher mean Body Mass Index and prevalence of diabetes and cigarette smokers; but also with higher HDL cholesterol and a more favourable alcohol intake pattern. Less-educated women had higher mean systolic blood pressure, Body Mass Index and HDL cholesterol and were more likely to have diabetes. Men and women in the low educational class had a 2-fold increase in ischaemic stroke and CHD incidence, respectively, after controlling for major risk factors. Education was not associated with CHD incidence in men. Higher ischaemic stroke rates were observed among more educated women. CONCLUSION: In this northern Italian population, the association between education and cardiovascular risk seems to vary by gender.

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

OBJECTIVES: We 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 >or=130 mmHg and/or diastolic blood pressure >or=85 mmHg, fasting serum glucose >or=110 mg/dl, high-density lipoprotein plasma cholesterol or=150 mg/dl, waist circumference >or=102 cm (men) or 88 cm (women)], AHA (the American Heart Association; same cut-off of ATPIII except serum glucose >or= 100 mg/dl) and IDF [the International Diabetes Federation; mandatory criteria of visceral obesity with reduced cut-off of 94 cm (men) or 80 cm (women), and at least two criteria with the same cut-off as in AHA] for their impact on metabolic syndrome prevalence, cardiac organ damage, long-term risk of cardiovascular events and death for any cause and risk of developing diabetes mellitus, in-office and out-of-office hypertension and left ventricular hypertrophy (LVH). METHODS: In 2051 participants, we measured office, home and ambulatory blood pressure as well as metabolic, anthropometric and echocardiographic variables. Measurements were performed between 1990 and 1992 and repeated 10 years later. Information on long-term incidence of cardiovascular events and all-cause deaths was also collected. RESULTS: Prevalence of metabolic syndrome was significantly greater when using the AHA and IDF as compared to the ATPIII definition. Prevalence of LVH was higher in participants with than without metabolic syndrome and similar for the three definitions. Over 12-year follow-up, there were 179 cardiovascular events and 233 deaths for any cause. The risk of cardiovascular events and death was markedly greater for participants with as compared with those without metabolic syndrome, regardless of the definition of metabolic syndrome. This was the case also for the risk of new-onset diabetes mellitus, office, home and ambulatory hypertension and new-onset LVH. CONCLUSION: Risks of fatal and nonfatal cardiovascular events, diabetes mellitus, hypertension and LVH were similar for the three definitions of metabolic syndrome. However, the AHA and IDF definitions are more sensitive than that of ATPIII in identifying metabolic syndrome condition.

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

BACKGROUND: Phenotypic 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 RESULTS: We studied 1550 adults aged 25-74 years, not on any antihypertensive treatment, resident in Monza, Italy (PAMELA study) all of whom had home, clinic and ambulatory BPs measured. We analysed 3705 single nucleotide polymorphisms (SNPs) (1324 typed and 2381 imputed) across 168 genes for association with these traits. No SNP achieved an experiment wide significance level of P less than 3 x 10 for any of the phenotypes studied. We selected 28 top candidate SNPs for further analysis of phenotypic heterogeneity and sexual dimorphism using a gene-centric strategy calculating empirical P values by permutations within each gene by including genic SNPs with an r less than 0.5. The association signals were not consistent across all the BP phenotypes, whether compared by genes or by physiological pathways. The top SNPs in WNK1, ADRA1A, ADRA1B, DRD1, NOS1 and PON3 showed significant sex interaction for BP and when analysed separately by sex showed evidence of dimorphism with opposite direction of effect for the same allele in the two sexes. CONCLUSION: In the largest study of its kind, we show that sex and BP measurement methods have a significant impact on association signals. These findings might explain previous inconsistencies in studies on cardiovascular candidate genes and should have major implications for the design and interpretation of association studies.

Simultaneous validation of the SunTech 247 diagnostic station blood pressure measurement device according to the British Hypertension Society protocol, the International Protocol and the Association for the Advancement of Medical Instrumentation standards.

OBJECTIVE: SunTech 247 is an oscillometric blood pressure (BP) monitor manufactured by SunTech Medical Inc., Morrisville, North Carolina, USA. The aims of this study were (i) to determine its accuracy using the 1993 modified British Hypertension Society (BHS) protocol, the 2002 International Protocol (IP) and the 2002/2003 Association for the Advancement of Medical Instrumentation (AAMI) standards, (ii) to compare the performance of BHS protocol and IP. METHODS: Systolic BP (SBP) and diastolic BP (DBP) were recorded to the nearest 2 mmHg and measured with the arm supported at heart level. For each participant, nine sequential same arm measurements were taken by two trained observers, comparing the device to standard mercury sphygmomanometers. Procedures and data analysis were carried out following protocols guidelines. RESULTS: First, we recruited 33 participants required by the IP. Then, data collection continued to obtain 85 participants for the BHS protocol/AAMI standard. Readings differing by less than 5, 10 and 15 mmHg for SBP and DBP fulfilled IP recommendations. According to the BHS protocol, for the better observer, the percentage of test device readings differing from the mercury standard by 5, 10 and 15 mmHg or less were: 92.9, 100 and 100% for SBP and 94.9, 98.8 and 99.6% for DBP. The mean differences +/- standard deviation between the device and mercury sphygmomanometer readings were 1.7 +/- 3.1 mmHg for SBP and 1.1 +/- 3.2 mmHg for DBP, achieving AAMI requirements. Standard deviation of mean differences were 2.4 for SBP and 2.1 for DBP, following the IP, and 3.1 and 3.2, respectively, for BHS protocol. The variance of all 99 differences (total deviance), with 98 degree of freedom, was 585.6 for SBP and 444.1 for DBP. The 33 differences obtained from the mean differences for each participant (between-subject variance), with 32 degree of freedom, were 275.6 and 152.1, respectively. F test was 1.83 with P = 0.0191 for SBP, and 1.07 (P = 0.3936) for DBP. CONCLUSION: (i) The device achieved the requirements stated by the 2002 IP, fulfilled the standards stated by the AAMI, and on the basis of the standards indicated by the 1993 modified BHS protocol, can be classified as 'A' grade both for SBP and DBP. Therefore, SunTech 247 may be recommended for clinical use, (ii) IP and BHS protocol provide complementary features for device validation; the comparison of total deviance and between-subject variance confirms the estimates of IP authors for SBP.

Left ventricular hypertrophy increases cardiovascular risk independently of in-office and out-of-office blood pressure values.

OBJECTIVES: Previous 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 account not only classical risk factors but also home and ambulatory BP values, which have been shown to have an important independent prognostic impact. METHODS: In 1716 patients belonging to the 'Pressioni Arteriose Monitorate E Loro Associazioni' population of Monza, we quantified left ventricular mass index and identified LVH by standard cutoff values. We also measured clinic, home and 24-h ambulatory BPs together with serum glucose and lipids. RESULTS: During a follow-up of 148 months, the rate of fatal and nonfatal (hospitalizations) cardiovascular events as well as of all-cause death was markedly greater (four-fold to five-fold) in patients as compared with those without LVH. In LVH individuals, the increased risk remained significant even when data were adjusted for a large number of other confounding factors including home BP, 24-h mean BP and ambulatory BP. Results were similar when left ventricular mass was indexed by height and body surface area. A 10% increase in left ventricular mass index was associated with a significant increase in cardiovascular risk or all-cause deaths. In multivariate analysis, left ventricular mass index was always an independent predictor of cardiovascular events and death for any cause. CONCLUSION: Our data provide evidence that LVH is an important risk factor even when the contribution of different BPs to risk is fully taken into account.

Long-term risk of sustained hypertension in white-coat or masked hypertension.

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 <125/79 mm Hg or home BP <132/82 mm Hg. Corresponding values for MHT diagnosis were office BP <140/90 mm Hg, 24-hour BP > 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.

Increased long-term risk of new-onset diabetes mellitus in white-coat and masked hypertension.

OBJECTIVE: A 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. METHODS: In 1412 individuals of the Pressioni Arteriose Monitorate E Loro Associazioni study stratified for sex and age decades, we measured office, home and 24-h ambulatory blood pressure together with fasting plasma glucose and other metabolic variables. This allowed to identify patients with white-coat, masked, sustained hypertension and true normotension. RESULTS: Over a 10-year period, the increase in plasma glucose and the incidence of new-onset diabetes (plasma glucose > or =126 mg/dl or use of antidiabetic drugs) was significantly greater in individuals with white-coat and masked hypertension than in those with 'true' normotension (age and sex-adjusted risk 2.9 and 2.7, respectively), the increase being similar to that of sustained hypertensive individuals. The adjusted risk showed a marked increase when development of an impaired fasting glucose condition was also considered, and the results were similar when individuals reporting antihypertensive drug treatment were excluded or white-coat and masked hypertension were identified by office versus home blood pressure. The increased risk of new-onset diabetes become no more significant when data were adjusted for initial blood glucose and BMI, which, at a multivariate analysis, were the most significant predictors of this condition, with only a small although significant contribution of the initial blood pressure. CONCLUSION: Thus, white-coat and masked hypertension are associated with a long-term greater progression of blood glucose abnormalities and an increased risk of developing diabetes. This is largely accounted for by the metabolic abnormalities that are frequent components of these conditions.

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

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

Accuracy evaluation of the 'Cardiette BP one' ambulatory blood pressure monitor.

OBJECTIVE: Blood pressure (BP) 'Cardiette BP one' system (BP one) is an oscillometric ambulatory BP monitor manufactured in Italy in conformity to current regulations for medical devices. We decided to determine the accuracy of measures made with BP one, using the protocol of the British Hypertension Society published in 1990, and revised in 1993, for evaluating the accuracy of BP measurement devices. METHODS: The evaluation included before-use calibration, in-use assessment, after-use calibration, and static device validation that involved 85 participants. RESULTS: The mean difference between manual readings with sphygmomanometer and automatic ones with the device were -0.36+/-5.74 (mean+/-SD) for systolic values and 2.52+/-4.87 for diastolic values. On the basis of the percentages of measurements differing from the mercury sphygmomanometer standard by

Preventive potential of body mass reduction to lower cardiovascular risk: the Italian Progetto CUORE study.

OBJECTIVE: To estimate effects of weight change on incidence of major cardiovascular events in the Italian population-based Progetto CUORE. METHODS: Prospective observation in 12 Italian population-based cohorts on etiology of cardiovascular disease. Twenty-thousand six-hundred-forty-seven men and women aged 35-69 years without previous CVD, examined at baseline between 1984 and 1993 and followed for median time 8.5 years, with validated first cardiovascular events. Standardised anthropometric variables, lifestyle and biochemical risk factors for CVD; major cardiovascular events as end-points. RESULTS: Linear regression between BMI and major CVD risk factors was combined with Cox coefficients from a prediction model of CVD, CHD and stroke using major risk factors as dependent variables. Estimated cardiovascular risk reductions with BMI lowered by 1 to 3 U were: for men 3.8% to 10.9% for all cardiovascular events, 4.2% to 12.1% for CHD, and 2.3% to 6.9% for stroke; for women 2.8% to 8.1% for all cardiovascular events, 3.4% to 9.8% for CHD, and 2.1% to 6.2% for stroke. CONCLUSIONS: Body weight level influences cardiovascular disease risk in the Italian population.

HIV and metabolic syndrome: a comparison with the general population.

OBJECTIVE: To compare the prevalence of metabolic syndrome (MS) in HIV-positive patients with that from a sample of a general Italian population. DESIGN: Cross-sectional study. METHODS: A total of 1263 HIV-infected patients 18 years of age or older were recruited in 18 centers for infectious diseases in northern and central Italy. Controls were 2051 subjects aged 25 to 74 years representative of the residents of Monza, a town in Milan province, who were enrolled in the Pressioni Arteriose Monitorate E Loro Associazioni study. RESULTS: The prevalence of MS in the HIV group was 20.8%, whereas in the control group, it was only 15.8%, with the difference being statistically significant. The age- and gender-adjusted risk of having MS in HIV-infected patients was twice as great as that in controls. Compared with controls, HIV-infected patients had a greater prevalence of the impaired fasting glucose, increased plasma triglycerides, and reduced high-density lipoprotein cholesterol components. MS prevalence was similar in treated and never-treated HIV-infected patients, and so were the various MS components. CONCLUSIONS: The risk of MS is greater in HIV-infected patients compared with the general population because of a greater prevalence of lipid and glucose abnormalities. The prevalence of MS and its components is similar in treated and untreated HIV-positive patients.

Long-term prognostic value of blood pressure variability in the general population: results of the Pressioni Arteriose Monitorate e Loro Associazioni Study.

The hypothesis has been advanced that cardiovascular prognosis is related not only to 24-hour mean blood pressure but also to blood pressure variability. Data, however, are inconsistent, and no long-term prognostic study is available. In 2012 individuals randomly selected from the population of Monza (Milan), 24-hour ambulatory blood pressure (Spacelabs 90207) was measured via readings spaced by 20 minutes. Systolic and diastolic blood pressure variability was obtained by calculating the following: (1) the SD of 24-hour, day, and night mean values; (2) the day-night blood pressure difference; and (3) the residual or erratic blood pressure variability (Fourier spectral analysis). Fatal cardiovascular and noncardiovascular events were registered for 148 months. When adjusted for age, sex, 24-hour mean blood pressure, and other risk factors, there was no relationship between the risk of death and 24-hour, day, and night blood pressure SDs. In contrast, the adjusted risk of cardiovascular death was inversely related to day-night diastolic BP difference (beta coefficient=-0.040; P<0.02) and showed a significant positive relationship with residual diastolic blood pressure variability (beta coefficient=0.175; P<0.002). Twenty-four-hour mean blood pressure attenuation of nocturnal hypotension and erratic diastolic blood pressure variability all independently predicted the mortality risk, with the erratic variability being the most important factor. Our data show that the relationship of blood pressure to prognosis is complex and that phenomena other than 24-hour mean values are involved. They also provide the first evidence that short-term erratic components of blood pressure variability play a prognostic role, with their increase being accompanied by an increased cardiovascular risk.