Silent cerebrovascular damage and its early correlates in essential hypertensive patients.

This study tested the association between cognitive functions, cerebrovascular damage, and cerebrovascular reactivity in 71 essential young hypertensives (age matched) and 22 normotensives (age matched). They underwent ambulatory blood pressure monitoring, neurocognitive tests, cerebral magnetic resonance, and transcranial Doppler. Twenty-three percent of patients showed more than 10 white matter lesions and 8% showed none. No control subjects showed more than 10 white matter lesions and 90% of normal controls showed no lesions. Patients with more than 10 white matter alterations had longer hypertensive story and showed significant lower nocturnal blood pressure fall. Pulsatility index was correlated with the number of white matter lesions.

White-coat effect among older patients with suspected cognitive impairment: prevalence and clinical implications.

OBJECTIVES: To evaluate the prevalence of white-coat effect (WCE), and its association with individual anxiety and insight of disease, among older patients evaluated for suspected cognitive impairment. METHODS: This prospective cohort study, conducted in an Alzheimer Evaluation Unit, involved patients aged 55 years or older with suspected cognitive impairment. WCE was defined as a difference of at least 20 mmHg in systolic or 10 mmHg in diastolic blood pressure (BP) measured either by a physician during the visit or by a nurse (before and after the visit), compared with home self-blood pressure measurement (SBPM). Severity of cognitive impairment was evaluated through the Mini-Mental State Examination (MMSE); the Clinical Insight Rating Scale (CIR) and the Guidelines for the Rating for Awareness Deficits (GRAD) were used to evaluate the subject's insight; anxiety disorder was evaluated using the seven-question Generalized Anxiety Disorder scale (GAD-7). RESULTS: Among 273 subjects, prevalence of WCE was 52%, 32.6% and 30.4%, according to physician and nurse BP measurements, respectively (p = 0.000). Prevalence of WCE did not differ between patients diagnosed with and without dementia, but was higher among patients with than in those without anxiety disorder (70.7% vs 38.2%, p = 0.000). Positive relations were observed between severity of anxiety and insight of disease, which were both inversely related with severity of cognitive impairment. CONCLUSIONS: WCE is extremely common and is correlated to individual anxiety and insight of disease among older outpatients with suspected cognitive impairment; overestimation of hypertension severity might lead to unnecessary drug treatment and greater health costs in this setting.

Hypertension and cognitive function.

Arterial hypertension, cerebrovascular disease, and dementia are related pathologies. This paper has reviewed comparatively the incidence of arterial hypertension and adult-onset dementia disorders. Hypertension is associated with cerebrovascular disease, which is in turn associated with dementia. It is the most important modifiable risk factor for stroke, which is a recognized cause of vascular dementia. In terms of pathophysiology of hypertensive brain damage, several hypotheses were developed, such as that vascular alterations induced by hypertension can induce lacunar or cortical infarcts and leucoaraiosis, that hypertension is responsible for cerebrovascular disease and acts into the contest of a pre-existing subclinic Alzheimer's disease (AD), that hypertension determines neurobiologic alterations (such as beta-amyloid accumulation) resulting in neuropathologic damage, and that aging and cerebrovascular risk factors act together to cause cerebral capillary degeneration, mitochondrial disruption, reduced glucose oxidation, and reduced ATP synthesis. The consequence of these alterations are neuronal death and dementia. Macroscopic results of these mechanisms are the so-called white matter lesions (WML), the significance of which is analyzed. Increasing clinical evidence suggests a close relationship between the reduction of elevated blood pressure and countering of both vascular dementia and AD. Antihypertensive treatment probably influences cognitive performances and prevents cognitive function alterations and the development of dementia. It is therefore important to evaluate as soon as possible cognitive functions of hypertensive patients.

Clinical implications of white-coat effect among patients attending at a lipid clinic.

We evaluated clinical implications of the white-coat effect (WCE) in cardiovascular (CV) risk stratification in the primary prevention setting of a Lipid Clinic. We compared home self blood pressure measurement (SBPM) with office blood pressure (BP) readings and BP measured by a nurse before and after the visit on consecutive subjects, free of previous CV diseases, attending at a Lipid Clinic for a first visit. Additionally, we evaluated whether and to what extent the difference between these measurements affect the 10-year cardiovascular risk calculated according to current guidelines. Mean home self-measured systolic and diastolic BP values were significantly lower than physician's and nurse's readings (p=0.000). A WCE was observed in 60.3% of patients during the physician's visit, and in 33.9% and 36.6% of nurse's measurements before and after visit, respectively. Compared with computation of SBPM, inclusion in risk predictive model of systolic BP values obtained by physician and nurse (before or after visit) resulted in significantly higher calculated CV risk (p=0.000) and in a higher risk-class allocation in 16.5%, 8.5% and 9.4% of patients, respectively (p=0.000). Our findings show that among patients attending at a Lipid Clinic there is a high prevalence of WCE, which is roughly halved when nurse's BP measurements were considered. Nurse's BP measurements before or after the doctor's visit may reduce, but not eliminate at all, the clinic overestimation of BP. The WCE associated with physician's office visit carries a substantial probability of 10-year CV risk overestimation in the primary prevention setting.

[Adverse drug reactions as cause of visit to the emergency department: incidence, features and outcomes]. / Le reazioni avverse ai farmaci come causa di ricorso al Pronto Soccorso: incidenza, caratteristiche e risultati.

The aim of the study was to determine incidence, features and outcomes of the adverse drug reactions (ADR) among emergency department (ED) visits of S. Giovanni Battista Hospital in Turin. We evaluated 16.055 patients among ED visits in a period of five months; the mean age was 59.6 +/- 20.2 year (range 17-93 y; 8.054 women and 8.001 men); 426 (2.6%) had ADRs, and 91 (21.4%) were admitted to the hospital. In multivariate analysis only the number of medicines was positive correlated with ADR. The drugs most frequently ADR-related were: anticoagulants (21.8%), antibiotics (17.6%), NSAIDs (9.9%), hypoglycaemic agents (9.6%), ACE-inhibitors (4.7%), antipyretics (4%) and alfa-litics (3.3%); the most common clinic events were: gastrointestinal bleeding (21.1%), rash (19.7%), confusion (23.9%), hypoglycaemia (8.4%), dyspnoea (7.0%), syncope and wheezing (5.6%), gastrointestinal bleeding (2.8%), anaemia (2.8%), haematomas (4.2%), vomiting (4.2%). Factor associated with increased ADR-hospital admission were increasing age (over 65 years old), gastrointestinal diseases, dementia and ADL-dependence. ADR-patients' Emergency Department mortality was higher than noADR-patients' one. The mean duration of hospitalization was higher in ADR-patients. It is necessary to reduce the number of drugs and improve studies and prevention strategies targeted to reduce the impact of ADR, specially in the elderly population.