Nocturnal hypertension and organ damage in dippers and nondippers.

BACKGROUND: The relationship between high nocturnal blood pressure (BP), organ damage and the dipping/nondipping status is poorly defined. We investigated whether a consistent dipping/nondipping pattern defined on the basis of two 24-h ambulatory BP monitorings (ABPMs) is associated with subclinical organ damage in untreated hypertensive patients with elevated nighttime BP. METHODS: All subjects underwent the following procedures: cardiac and carotid ultrasonography, 24-h urine collection for microalbuminuria (MA), and ABPM over two 24-h periods within 4 weeks. Nocturnal hypertension was defined according to current guidelines (i.e., nighttime systolic BP (SBP) ≥120 and/or diastolic BP ≥70 mm Hg) and nondipping status as an average reduction in SBP at night <10% compared with day-time values. RESULTS: Among 343 subjects, 199 were dippers and 144 nondippers. No differences were found in clinical variables, average 48-h BP, left ventricular mass, carotid intima-media (IM) and urinary albumin excretion between the groups. This was also the case for prevalence rates of left ventricular hypertrophy, carotid IM thickening or plaque and MA. Finally, no relationship was found between the markers of organ damage and BP fall at night. CONCLUSIONS: In the presence of nocturnal hypertension, dippers have a similar subclinical cardiac and extra-cardiac organ damage as their nondipper counterparts. These data suggest that therapeutic strategies only addressing the nondipper pattern may be insufficient to protect hypertensive subjects against the dangerous effects of elevated nocturnal BP.American Journal of Hypertension, (2012); doi:10.1038/ajh.2012.49.

Age related prevalence of severe left ventricular hypertrophy in essential hypertension: echocardiographic findings from the ETODH study.

AIM: We sought to investigate the prevalence and correlates of severe left ventricular hypertrophy (LVH) in relation to age in a large cohort of essential hypertensives referred to a single outpatient hypertension clinic. METHODS: A total of 3752 (mean age 53±13 years, 53% men) untreated (29.5%) and treated hypertensive patients categorized in three age groups (I: 18-40 years; II: 41-64 years; III: ≥65 years) were considered for this analysis. All patients underwent extensive investigations searching for target organ damage. LVH, defined as LV mass ≥49/45 g/m(2.7) in men/women, respectively, was graded as mild, moderate and severe according to Lang's report. RESULTS: LVH prevalence was 29.4% in group I, 48.2% in group II and 63.6% in group III. Overall, more than one fourth of patients with LVH had a severely increased LV mass index; the likelihood of having severe LVH was two- and four-fold higher in elderly hypertensives than in their middle-aged and young counterparts, respectively. Increasing age and LVH degree were both associated with a greater prevalence of concentric LV geometry as well as of extra-cardiac organ damage (i.e. carotid intima-media thickness). CONCLUSIONS: LVH is a highly prevalent organ damage in essential hypertensives, particularly in the elderly, who exhibited a more severe increase of LV mass index, higher relative wall thickness and extra-cardiac organ damage compared with young and middle-aged sub-groups. Our findings suggest that the assessment of cardiovascular risk by grading LVH rather than simply defining the presence/absence of this cardiac phenotype could improve therapeutic strategies in the hypertensive population, particularly in the elderly.

Association of left atrial enlargement with left ventricular hypertrophy and diastolic dysfunction: a tissue Doppler study in echocardiographic practice.

BACKGROUND: Left atrial (LA) enlargement is a powerful risk factor for cardiovascular diseases; little information is available about its prevalence and correlates in subjects free of overt cardiac disease seen in echocardiographic practice. AIM: We evaluated the prevalence of LA enlargement (LAE) and the relationship with left ventricular (LV) mass and diastolic function in subjects with preserved LV systolic function referred to an echocardiographic study for routine clinical indications. METHODS: 1104 subjects (mean age 58 ± 16 years, 46% men, 57% hypertensives) underwent a comprehensive echo-Doppler examination. LAE and LV hypertrophy (LVH) were defined as LA volume index (LAVI) >29 ml/m(2) and LV mass index (LVMI) >50 g/h(2.7), respectively. Abnormalities of LV relaxation and LV filling were diagnosed by age-related thresholds of lateral annular velocity (Ei) and by early mitral flow velocity to Ei ratio (E/Ei) ≥16, respectively. RESULTS: Overall, 10% of echocardiographic examinations fulfilled the criteria for LAE, 46% for LVH, 45% for altered LV relaxation and 5% for altered LV filling index. LVH progressively increased from 25% to 75% across LAVI quartiles. More patients in the highest quartile exhibited abnormal indexes of LV relaxation and LV filling compared with lower quartiles. In multivariate analysis, LV mass index (ß = 0.408), age (ß = 0.188), E/Ei ratio (ß = 0.140) and Ei (ß = 0.140) emerged as major correlates of LAE (p at least <0.01 for all). CONCLUSIONS: LAE is a frequent finding in patients with preserved systolic function seen in current practice; this abnormality is strongly related to LVH and to diastolic dysfunction. Early detection of LAE may identify patients at higher cardiovascular risk and promote appropriate prevention strategies.

Nocturnal blood pressure in untreated essential hypertensives.

AIM. Prevalence, correlates and reproducibility of nocturnal hypertension (NH) as defined by fixed cut-off limits in uncomplicated essential hypertension are poorly defined. Therefore, we assessed such issue in a cohort of 658 untreated hypertensives. METHODS. All subjects underwent procedures including cardiac and carotid ultrasonography, 24-h urine collection for microalbuminuria, ambulatory blood pressure monitoring (ABPM), over two 24-h periods within 4 weeks. NH was defined according to current guidelines (i.e. night-time blood pressure, BP ? 120/70 mmHg) and non-dipping status as a reduction in average systolic (SBP) and diastolic BP (DBP) at night lower than 10% compared with daytime values. RESULTS. A total of 477 subjects showed NH during the first and second ABPM period; 62 subjects had normal nocturnal BP (NN) in both ABPM sessions. Finally, 119 subjects changed their pattern from one ABPM session to the other. Overall, 72.5% of subjects had reproducible NH, 18% variable pattern (VP) and 9.5% reproducible NN. In the same group, figures of reproducible non-dipping, variable dipping and reproducible dipping pattern were 24%, 24% and 52%, respectively. Among NH patients, 56% of whom were dippers, subclinical cardiac organ damage was more pronounced than in their NN counterparts. CONCLUSIONS. In uncomplicated essential hypertensives, NH is a more frequent pattern than non-dipping; NH is associated with organ damage, independently of dipping/non-dipping status. This suggests that options aimed at restoring a blunted nocturnal BP fall may be insufficient to prevent cardiovascular complications unless night-time BP values are fully normalized.

Is blunted heart rate decrease at night associated with prevalent organ damage in essential hypertension?

AIM: The association between a blunted decrease in day­night heart rate and subclinical organ damage has not been investigated earlier in human hypertension. Therefore, we assessed such an association in a cohort of 658 untreated essential hypertensive patients. METHODS: All patients underwent procedures including cardiac and carotid ultrasonography, 24-h urine collection for microalbuminuria, ambulatory blood pressure monitoring with simultaneous assessment of heart rate over two 24-h periods within 4 weeks. Nondipping heart rate was defined as a mean heart rate reduction at night lower than 10% compared with daytime values. RESULTS: A reproducible nocturnal dipping (heart rate decrease >10% in both the ambulatory blood pressure monitoring periods) and nondipping profile was found in 513 (78%) and 76 patients (12%), respectively; 69 hypertensive patients (10%) had a variable dipping profile. The three groups did not differ with regard to age, sex, body size, metabolic variables, office and ambulatory blood pressures, left ventricular mass, carotid intima-media thickness, carotid plaque and microalbuminuria. In a univariate analysis, the decrease in nocturnal heart rate did not correlate with any parameter of subclinical organ damage. CONCLUSION: Our findings from a cross-sectional study do not support the view that a flattened heart rate circadian rhythm is related to a prevalent organ damage in essential hypertension and that this altered pattern is a marker for subclinical cardiovascular disease. The prognostic significance of this finding should be defined by prospective studies.

Role of tissue Doppler imaging for detection of diastolic dysfunction in the elderly: a study in clinical practice.

BACKGROUND: The role of tissue Doppler imaging (TDI) in the assessment of diastolic dysfunction in elderly patients seen in echocardiographic practice is poorly defined. OBJECTIVE: The aim of this study was to investigate the prevalence of diastolic dysfunction in a cohort of elderly patients referred to an echocardiographic examination for routine clinical indications and to compare the findings obtained by conventional Doppler with those obtained by TDI. METHODS: A total of 457 elderly patients with preserved left ventricular (LV) systolic function (mean age 73 ± 5 years, 45% men, 76% with hypertension) underwent a comprehensive echo-Doppler examination; diastolic dysfunction was defined by the following conventional and TDI criteria: E/A ratio (ratio between transmitral peak velocity of E and A waves) <0.7 or >1.5 and lateral annular early diastolic peak velocity (Ei) <8 cm/sec, respectively. RESULTS: Diastolic dysfunction was present in 130 patients (28.4%) according to the conventional Doppler criterion, namely 119 (26.0%) because of E/A <0.7 and 11 because of E/A >1.5. A higher proportion of participants (60.1%) had LV diastolic dysfunction according to TDI. Notably, more than one-half of the patients with 'normal' diastolic function by conventional criterion exhibited an abnormal Ei value. CONCLUSIONS: A large proportion of elderly patients with normal E/A ratios may have more subtle alterations in LV diastolic mechanics characterized by a reduced annular motion velocity. Thus, evaluation of diastolic function by the simple E/A ratio may markedly underestimate diastolic abnormalities. This finding supports the view that diastolic function should be routinely assessed by comprehensive Doppler methodologies including both conventional and tissue Doppler measurements in order to improve the management of elderly patients seen in clinical practice.

Left ventricular hypertrophy detection and body mass index in essential hypertension.

BACKGROUND AND AIM: Weight and height are two major determinants of left ventricular mass (LVM); the anthropometric parameter to which LVM should be normalized remains, however, debated. In a population of hypertensives, we compared the prevalence of left ventricular hypertrophy (LVH) defined by two indexation criteria of LVM in different subgroups of body mass index (BMI). METHODS: A total of 4468 essential hypertensives included in the Evaluation of Target Organ Damage in Hypertension (ETODH), were divided in four groups according to BMI thresholds: lean (BMI<20 kg/m(2), 4.5%), normal (20-24.9 kg/m(2), 36.5%), overweight (25-29.9 kg/m(2), 41.9%) and obese (≥ 30 kg/m(2), 17.1%). All patients underwent quantitative echocardiography; LVH was defined by two criteria of LVM indexation: (A) ≥ 116 g/m(2) in men and ≥ 96 g/m(2) in women; (B) ≥ 49 g/m(2.7) in men and ≥ 45 g/m(2.7) in women. RESULTS: Overall, 44.9% of the patients were found to have LVH by criterion A, 48.2% by criterion B and 37.0% by both criteria. Prevalence rates of LVH in the four BMI groups were 34.3%, 40.5%, 47.3%, 53.9% by criterion A, 19.8%, 37.0%, 53.6%, 69.7% by criterion B, and 14.2%, 30.9%, 41.5%, 47.8% by both criteria, respectively (p at least <0.05 for all). CONCLUSIONS: Our findings show that LVH prevalence in both overweight and obese hypertensives is higher when LVM is normalized to height(2.7) compared with body surface area (BSA), whereas the opposite trend occurs in normal weight/lean hypertensives. Thus, the risk related to LVH is underestimated when the LVH/height(2.7) criterion is applied to lean/normal weight individuals and the LVH/BSA criterion in overweight/obese individuals.

Prevalence and clinical correlates of right ventricular hypertrophy in essential hypertension.

AIM: Right ventricular hypertrophy (RVH) has been reported to be a component of cardiac damage in systemic hypertension; this evidence, however, is based on small studies and major determinants of biventricular hypertrophy are still undefined. Thus, the prevalence and clinical correlates of RVH have been investigated in essential hypertension. METHODS: A total of 330 untreated and treated uncomplicated essential hypertensives consecutively attending a hospital out-patient hypertension clinic were considered for the analysis. All individuals underwent a quantitative echocardiographic examination as well as extensive clinical and laboratory investigations. RVH was defined by an anterior RV wall thickness equal or higher than 3.1/3.0 mm/m2 in men and women, respectively, and left ventricular hypertrophy (LVH) by LV mass index equal or higher than 51/47g/m2.7 in men and women, respectively. RESULTS: Overall, 114 (34.5%) patients fulfilled the criteria for LVH and 111 (33.6%) for RVH; normal cardiac morphology was observed in 164 patients (49.6%), isolated RVH in 52 (15.7%), isolated LVH in 55 (16.6%) and bi-ventricular hypertrophy in 59 (17.8%). In a logistic regression analysis, modifiable risk factors such as abdominal obesity (OR 3.41, CI 1.73-6.74, P = 0.0004), LV mid-wall fractional shortening (OR 2.48, CI 1.26-4.85, P = 0.008), fasting blood glucose (OR 2.47, CI 1.25-4.89, P = 0.009) and systolic blood pressure (OR 2.39, CI 1.19-4.82, P = 0.014) were the major independent correlates of biventricular hypertrophy. CONCLUSION: RVH is commonly found in systemic hypertension and is associated with LVH (i.e., biventricular hypertrophy) in approximately one-fifth of the patients seen in a specialist setting. The clinical correlates of biventricular hypertrophy suggest that this phenotype is associated with a profile of very high cardiovascular risk.

Body mass index, nocturnal fall in blood pressure and organ damage in untreated essential hypertensive patients.

AIM: We sought to investigate the relationship between body mass index (BMI) and parameters derived from 48-h ambulatory blood pressure monitoring (ABPM) as well as organ damage in human hypertension. METHODS: A total of 658 consecutive outpatients with grade 1 and 2 hypertension, never treated with antihypertensive medications underwent the following procedures: (i) routine examination, (ii) 24-h urine collection for microalbuminuria, (iii) ABPM over two 24-h periods within 4 weeks, (iv) echocardiography and (v) carotid ultrasonography. Each patient was classified as lean (BMI<25 kg/m2) or overweight/obese (> or =25 kg/m2) and according to the consistency of the dipping or nondipping status in the first and second ABPM period, as dipper (DD), nondipper and variable dipper. RESULTS: Mean 48-h, daytime and nighttime systolic BP or diastolic BP were superimposable in the lean (n=314) and overweight (n=344) group. Overweight patients had a reduced nocturnal BP drop compared with their lean counterparts; the prevalence of DD pattern, indeed, was 15% lower in the overweight group as a whole, with a 17% difference in men and 13% in women. The prevalence of left ventricular hypertrophy was higher in overweight than in lean patients (31.8 vs. 15.9% in men and 48.7 vs. 15.6% in women, P<0.01); this more pronounced cardiac involvement was associated with structural carotid alterations. CONCLUSION: This study, the first to investigate the relationship between BMI and nocturnal BP patterns as assessed by two ABPM sessions, shows that overweight hypertensive patients are more likely to have a reduced nocturnal fall in BP and a greater cardiac and extracardiac organ damage as compared with their lean counterparts despite a similar overall BP load.

Metabolic syndrome and multiple organ damage in essential hypertension.

AIM: We investigated the prevalence of the metabolic syndrome (MS) in hypertensive patients categorized according to the number of markers of organ damage (OD) in order to assess the value of a systematic search for cardiac and extra-cardiac OD in the MS setting. METHODS: A total of 3119 untreated and treated essential hypertensives included in the Evaluation of Target Organ Damage in Hypertension (ETODH), an observational registry of hypertension-related OD, were considered for this analysis. All patients underwent extensive investigation for left ventricular hypertrophy (LVH) or LV concentric remodeling (cardiac OD), carotid plaques and/or intima-media thickening (vascular OD) and microalbuminuria (MA) and/or increased serum creatinine (renal OD). Subjects were classified as: positive for none (group 0), one (group I), two (group II) or three markers (group III) of OD. RESULTS: MS prevalence rates progressively rose across the groups stratified according to the OD score, reaching a 2.3-fold increase in group III compared with their MS counterparts in group 0. The distribution of subjects with and without the MS across the groups was 15% vs 29% (group 0), 32% vs 38% (group I), 39% vs 26% (group II) and 14% vs 7% (group III), respectively. Thus, subjects having two or three markers of OD were 53% among those with MS and 33% (p<0.01) among those without it. CONCLUSION: Our findings indicate a strong association between the MS and OD by showing that a clustering of two or three markers of OD is the prevalent cardiovascular phenotype in MS hypertensives referred to a specialist center and call for a systematic evaluation of cardiac and extracardiac OD in this setting.

The Hyper-Pract Study : a multicentre survey on the accuracy of the echocardiographic assessment of hypertensive left ventricular hypertrophy in clinical practice.

Left ventricular hypertrophy (LVH) assessed by echocardiography has a relevant impact in clinical decision making in hypertensive patients. We investigated the precision and accuracy of hypertensive LVH determination in current clinical practice by a regional-based survey. The study included 211 patients with essential hypertension consecutively attending six hospital outpatient hypertension clinics in the northern Italian region of Lombardy; all subjects had undergone an echocardiographic examination for hypertension-related problems in a non-academic or research ultrasound laboratory within 2 years. The original echocardiographic report was examined to ascertain whether the diagnosis of LVH was based on calculation of left ventricular (LV) mass according to validated formulae and indexed to body size (primary outcome) and whether LV geometrical patterns and indices of diastolic function were provided (secondary outcome). A total of 211 echocardiograms performed by 120 physicians operating in 73 different hospital and out-of-hospital ultrasound laboratories were collected. Absolute LV mass, LV mass index and relative wall thickness were calculated in 45.5%, 24.6% and 12.3% of the cases, respectively. Parameters of LV diastolic filling were measured in two-thirds of the cases and estimation of E/A ratio was provided by less than 20% of the examinations. This study shows that a large majority of echocardiographic examinations, routinely performed in hypertensive subjects in order to detect cardiac damage, do not report qualifying data on LV mass, LV geometry and diastolic function. These results indicate that a quantitative assessment of LVH and LV function is rarely provided in clinical practice.

Prevalence and correlates of multiple organ damage in a never-treated hypertensive population: role of ambulatory blood pressure.

AIM: Available evidence on multiple target organ damage (TOD) in the early phases of essential hypertension is scanty. We examined the prevalence and correlates of multiple TOD in never-treated patients with recently diagnosed hypertension. METHODS: A total of 602 consecutive outpatients with grades 1 and 2 hypertension underwent the following procedures: (i) routine examination, (ii) 24-h urine collection for microalbuminuria, (iii) ambulatory blood pressure monitoring over two 24-h periods within 4 weeks, (iv) echocardiography, (v) carotid ultrasonography. TOD at cardiac, vascular and renal levels was defined according to major international hypertension guidelines. RESULTS: Prevalence rates of patients negative for TOD (group I) or positive for one (group II), two (group III), or three (group IV) markers of TOD were as follows: 45, 33, 17 and 5%. In group II, alterations in left ventricular structure and geometry were more frequently present than carotid atherosclerosis and microalbuminuria; a similar trend was found in group III where a close association between cardiac and vascular, but not renal, signs of TOD was observed. In multiple regression analyses the risk of having three TOD was significantly related to age [odds ratio (OR): 2.11, 95% confidence interval (CI): 1.34-3.53], average 48-h systolic blood pressure (OR: 1.81, 95% CI: 1.22-2.95), smoking status (OR: 1.76, 95% CI: 1.22-2.86), male sex (OR: 1.36, 95% CI: 1.24-1.79), reproducible nondipping pattern (OR: 1.27, 95% CI: 1.12-1.61) and metabolic syndrome (OR: 1.16, 95% CI: 1.09-1.74). CONCLUSIONS: Our results show that: (i) a cluster of three TOD, namely at cardiac, carotid and renal levels, is not a common finding in a population of untreated essential hypertensive patients; a single TOD is present in about one-third of the patients and the parallel involvement of two organs in one-fifth of the cases; (ii) old age, ambulatory systolic blood pressure and smoking status are the most important predictors of multiple organ involvement.

Lack of association between serum uric acid and organ damage in a never-treated essential hypertensive population at low prevalence of hyperuricemia.

BACKGROUND: It is still undefined whether serum uric acid (SUA) is an independent risk factor for target organ damage (TOD) and cardiovascular events in human hypertension. We sought to investigate the association of SUA with subclinical cardiac, vascular, and renal alterations in never-treated uncomplicated essential hypertensives. METHODS: A total of 580 subjects with recently diagnosed (<1 year) grade 1 and 2 hypertension, categorized by sex and tertiles of SUA levels, were considered for this analysis. All subjects underwent extensive clinical, laboratory, and ultrasonographic investigations searching for cardiac and extracardiac TOD. RESULTS: Hyperuricemia (SUA >7.0 mg/dL in men and >6 mg/dL in women) was present in 8.3% of the patients. The overall prevalence of left-ventricular hypertrophy (LVH), carotid alterations, and microalbuminuria was 28%, 27%, and 8%, respectively. No differences in the prevalence rates of these TOD markers were present across all SUA tertiles in the entire population, as well as in both sexes. The SUA levels were similar in patients with and without LVH, carotid alterations, or microalbuminuria. When patients were classified according to the number of organs involved, those with multiple TOD (2 or 3 organs) had significantly higher SUA levels (5.1 +/- 1.3 or 5.2 +/- 1.4 mg/dL), as compared with those with a single or no organ involvement (4.9 +/- 1.3 or 4.9 +/- 1.4 mg/dL, P < .05). The association, however, between SUA levels and multiple TOD was not confirmed in a logistic regression analysis. CONCLUSIONS: Our findings do not support the role of SUA as an independent risk factor for subclinical TOD in a selected population of recently diagnosed uncomplicated hypertensives at low prevalence of hyperuricemia.

Reproducibility of dipping/nondipping pattern in untreated essential hypertensive patients: impact of sex and age.

OBJECTIVE: We aimed to evaluate the intrasubject short-term reproducibility of nocturnal blood pressure patterns (dipping/nondipping) in essential hypertensive patients in relation to age (<50 and > or =50 years) and sex. METHODS: A total of 619 never-treated essential grade 1 and 2 hypertensive patients (383 men, 236 women) underwent the following procedures: (1) repeated clinic blood pressure measurements, (2) routine examinations, (3) ambulatory blood pressure monitoring over two 24-h periods within 4 weeks. Dipping pattern was defined as a 10%, or more, reduction in average systolic blood pressure/ diastolic blood pressure at night compared to daytime values. RESULTS: Of the 407 patients showing a dipping pattern during the first ambulatory blood pressure monitoring period, 329 (80.1%) had the same pattern during the second ambulatory blood pressure monitoring recording. Of the 212 patients with a nondipping pattern during the first ambulatory blood pressure monitoring period, 140 (65.9%) confirmed the same pattern during the second ambulatory blood pressure monitoring period. Overall, 149 patients (24.1%) changed their initial nocturnal pattern at the second ambulatory blood pressure monitoring recording, without significant age and sex-related differences. Lower reproducibility rates of the nondipping as compared to the dipping pattern were found in the whole population as well as in men regardless of age and in younger but not in older women. CONCLUSIONS: These findings indicate that nocturnal blood pressure patterns have a limited short-term reproducibility in the whole study population as well as in different age and sex subgroups. As variability of nocturnal blood pressure patterns is not predicted by easy available clinical data, such as sex and age, a reliable classification of patients according to circadian blood pressure patterns should be obtained by repeating ambulatory blood pressure monitoring.

Age and target organ damage in essential hypertension: role of the metabolic syndrome.

OBJECTIVE: We sought to investigate the association of the metabolic syndrome (MS) with cardiovascular alterations in essential hypertensives in relation to age. METHODS: A total of 3266 untreated and treated hypertensive patients categorized in three age groups (I: 17 to 40 years; II: 41 to 64 years; III: >64 years) were considered for this analysis. All patients underwent extensive investigations searching for target organ damage (TOD). The MS was defined according to Advanced Technology Laboratories (ATP) III criteria. RESULTS: In the entire population, the risk of left ventricular hypertrophy (LVH), carotid abnormalities, and microalbuminuria increased by 2.5 (P = .003), 2.2 (P = .005), and 1.5 times (P = .01), respectively, in the presence of MS after adjusting for several confounders. Prevalence of LVH (group I: 39% v 22%; group II: 53% v 35%; group III: 69% v 52%, P < .01 for all), carotid thickening (group I: 8% v 2%; group II 29% v 19%; group III: 69% v 52%, P < .05 for all) and microalbuminuria (group I: 20% v 11%; group II: 16% v 8%; group III: 18% v 11%, P

How reliable is isolated clinical hypertension defined by a single 24-h ambulatory blood pressure monitoring?

BACKGROUND: Isolated clinical hypertension (ICH) is characterized by a persistently elevated clinic blood pressure in the presence of a normal day-time or 24-h ambulatory blood pressure (ABP). This definition is based on a single ABP monitoring (ABPM) and little attention has been focused on the reproducibility of this condition. OBJECTIVE: To investigate the reliability of the criteria currently recommended by major hypertension guidelines to detect ICH based on a single 24-h ABPM session. METHODS: A total of 611 never-treated grade 1 and 2 hypertensive patients (mean age 46 +/- 12 years) referred for the first time to our out-patient clinic, underwent repeated clinic blood pressure measurements, routine investigations, two 24-h periods of ABPM 1-4 weeks apart, cardiac and carotid ultrasound examinations. ABPM was always performed over a working day and the same daily activities were recommended during the two periods. ICH was diagnosed by the following criteria: (i) mean daytime values < 135/85 mmHg or (ii) mean 24-h blood pressure values < 125/80 mmHg during the first ABPM. RESULTS: The overall prevalence of ICH was 7.1% according to criterion (i) and 5.4% according to criterion (ii). Twenty (46.6%) of the 43 patients with mean daytime blood pressure values < 135/85 mmHg during the first ABPM, exceeded this cut-off value during the second ABPM period. Twenty-two (66.6%) of the 33 patients with mean 24-h blood pressure values < 120/80 mmHg during the first ABPM did not confirm a normal blood pressure profile during the second ABPM recording. Cardiovascular involvement was significantly lower in subjects with persistent normal ABP compared to those with non-reproducible ICH pattern or sustained hypertensives. CONCLUSIONS: These findings clearly indicate that: (i) the classification of ICH on the basis of a single ABPM, using the cut-offs suggested by major hypertension guidelines, has a limited short-term reproducibility and (ii) repeated ABPM recordings should be recommended to correctly diagnose patients with ICH and improve cardiovascular risk stratification.

Left ventricular hypertrophy and cardiovascular risk stratification: impact and cost-effectiveness of echocardiography in recently diagnosed essential hypertensives.

BACKGROUND: Echocardiography is more accurate than electrocardiography in the assessment of cardiac target organ damage related to hypertension, thus leading to a more precise stratification of total cardiovascular risk. However, ultrasound examination of the heart on a routine basis remains a matter of debate. OBJECTIVE: To evaluate the impact and cost-effectiveness of echocardiographic examination on global risk stratification in low and medium-risk hypertensive patients in relation to age and sex. METHODS: A total of 580 untreated hypertensive individuals (355 men and 225 women, mean age 47.8 +/- 11.4 years), classified at low to medium risk, according to routine clinical work-up suggested by the 2003 European Society of Hypertension/European Society of Cardiology guidelines, were included in the study. Total risk was reassessed by adding the results of ultrasound examination of the heart. Left ventricular hypertrophy (LVH) was defined as a left ventricular mass index of 125 g/m2 or more in men and 110 g/m2 or more in women. The impact of LVH in stratifying risk was assessed according to age (< 50 and > or = 50 years) and sex. RESULTS: According to routine classification, 16.3% (n = 93) of the 580 patients were considered to be at low added risk and 83.7% (n = 487) at medium added risk. In the whole population, echocardiographic LVH was found in 86 patients (14.8%) who were then reclassified in the high-risk stratum. The prevalence rates of patients reclassified in the high-risk class as a consequence of LVH detection, according to age and sex, were as follows: 8.9% in men under 50 years, 12.3% in women under 50 years, 26.7% in men aged 50 years and over and 15.3% in women aged 50 years and over. The cost per detected case of LVH was 595 euros in patients under 50 years of age and 290 euros in those 50 years of age and older. CONCLUSIONS: Our findings indicate that the prevalence of LVH, and consequently the probability of upgrading the total cardiovascular risk profile, is highest in the group of old hypertensive men; echocardiography has a limited impact on the risk reclassification in younger patients and an unfavourable cost-effectiveness profile. Our data thus do not support the systematic ultrasound assessment of the heart in all uncomplicated hypertensive individuals.

Effects of angiotensin II receptor blockade-based therapy with losartan on left ventricular hypertrophy and geometry in previously treated hypertensive patients.

BACKGROUND: The 2003 European Society of Hypertension/European Society of Cardiology (ESH/ESC) guidelines recommend angiotensin II receptor antagonists (AIIRAs) as a first-line therapy in hypertensives with left ventricular hypertrophy (LVH). AIM: We investigated the long-term effects of an AIIRA-based therapy on left ventricular (LV) structure and geometry in previously, unsatisfactorily treated essential hypertensive patients. METHODS: Sixty-eight consecutive patients referred to our hypertension hospital outpatient clinic with: (i) LVH (LV mass index, LVMI 51 g/m(2.7) in men and 47 g/m(2.7) in women), (ii) uncontrolled clinic blood pressure (BP140 and/or 90 mmHg) and (iii) antihypertensive therapy not including angiotensin-converting enzyme (ACE) inhibitors or AIIRAs were selected for this study. Two-dimensionally guided M-mode echocardiograms were carried out at baseline and after 6, 12, 18 and 24 months of follow-up. In all patients, losartan (50-100 mg/day, mean dose 82 mg/day) was added as first step to the previous therapy. Additional drugs, tailored to the single patient, were added, if necessary, to achieve target BP values (<140/90 mmHg). RESULTS: Overall, 59 patients completed the study with the primary efficacy measurements (LVMI) at all appropriate times. A significant reduction in both clinic systolic BP and diastolic BP was found across the entire period of study respect to baseline (-17/10, -22/12, -24/13 and -26/14 mmHg at 6, 12, 18 and 24 months, p < 0.001 respectively), leading to target clinic BP in 75.6% of cases. LVMI was significantly lower after 1 year of treatment (-11 +/- 12%, p < 0.05) with a further significant reduction at the end of treatment (-22 +/- 18%, p < 0.01). The proportion of patients achieving normalization of LVMI was 47.4% and more importantly, the prevalence of concentric LVH fell from 38.9% to 6.7% (p < 0.01). CONCLUSIONS: Our findings indicate that long-term intensive treatment based on the AIIRA losartan induced a normalization of LVH in about 50% of patients and more importantly caused an almost complete regression of concentric LVH, the most dangerous adaptive pattern. The transition from concentric to normal or eccentric LV geometry may have in these high-risk patients a favourable prognostic implication in addition to the recognized positive effect of reducing LVMI.

Short-term reproducibility of a non-dipping pattern in type 2 diabetic hypertensive patients.

BACKGROUND: Little information is available on the reproducibility of nocturnal variations in blood pressure in type 2 diabetic hypertensive patients. OBJECTIVE: We aimed to compare the intrasubject short-term reproducibility of a nocturnal non-dipping pattern and the prevalence of cardiac and extracardiac signs of target organ damage, in a group of type 2 diabetic hypertensive patients and in an age/gender-matched group of non-diabetic hypertensive subjects. METHODS: Thirty-six treated hypertensive patients with long-lasting type 2 diabetes (> 10 years duration) consecutively attending our hospital out-patient hypertension clinic (group I; mean age, 65 +/- 9 years), and 61 untreated non-diabetic subjects with grade 1 and grade 2 uncomplicated essential hypertension, matched for age and gender, and chosen from patients attending an outpatient clinic (group II; mean age, 65 +/- 5 years), were considered for this analysis. All patients underwent blood sampling for routine blood chemistry, 24-h urine collection for microalbuminuria, two 24-h periods of ambulatory blood pressure monitoring (ABPM) within a 4-week period, echocardiography, and carotid ultrasonography. A dipping pattern was defined as a greater than 10% reduction in the average systolic and diastolic blood pressure at night compared with average daytime values. RESULTS: A reproducible nocturnal dipping and non-dipping profile was found in 11 (30.6%) and 21 (58.3%) diabetic patients, respectively; while only in four (11.1%) patients was a variable dipping profile observed. Of the 23 patients with a non-dipping pattern during the first ABPM period, 21 (91.3%) also had this type of pattern during the second ABPM recording. In group II (non-diabetic hypertensive patients), 30 patients (49.2%, P < 0.05) had a dipping pattern, 13 patients (21.3%, P < 0.01) had a non-dipping profile pattern and 18 patients (29.5%, P < 0.01) had a variable dipping pattern. Of the 20 patients with a non-dipping pattern during the first ABPM period, 13 (65.0%) confirmed this type of pattern during the second ABPM recording. Finally, the prevalence of left ventricular hypertrophy (77.7 versus 41.4%, P < 0.01), carotid plaques (80.5 versus 38.3%, P < 0.01), carotid intima-media thickening (54.3 versus 44.0%, P < 0.05) and microalbuminuria (11.1 versus 2.0%, P < 0.01) was significantly higher in group I than in group II. According to a logistic regression analysis, diabetes, left ventricular hypertrophy and carotid plaques were the main independent predictors of the non-dipping (pattern in the overall population. CONCLUSIONS: These findings indicate that intrasubject variability of non-dipper pattern is lower in diabetic than in non-diabetic hypertensive patients, that classification of diabetic hypertensive patients as dipper or non-dipper on the basis of a single ABP recording is more reliable than in non-diabetic patients, and that the more frequent and reproducible non-dipping (pattern in diabetic patients is associated with a more prominent cardiac and extracardiac target organ damage.

Prevalence and correlates of aortic root dilatation in patients with essential hypertension: relationship with cardiac and extracardiac target organ damage.

OBJECTIVE: To assess the prevalence of aortic root dilatation in a large cohort of uncomplicated hypertensive patients and to evaluate the relations of aortic root size to different markers of cardiac and extracardiac target organ damage (TOD). METHODS: A total of 3366 untreated and treated essential hypertensive patients (mean age, 53 +/- 12 years) consecutively attending our out-patient hypertension clinic and included in the Evaluation of Target Organ Damage in Hypertension (an observational ongoing registry of hypertension-related TOD) were considered for this analysis. All patients underwent routine examinations, 24-h urine collection for microalbuminuria, echocardiography and carotid ultrasonography. RESULTS: Aortic root dilatation, defined by the sex-specific echocardiographic criteria of 40 mm in men and 38 mm in women, was present in 8.5% of men and in 3.1% of women. Compared with 3160 patients with normal aortic size, the group of 206 patients with an enlarged aortic root was older, had higher diastolic blood pressure values and included a greater fraction of subjects under antihypertensive treatment, with type 2 diabetes and metabolic syndrome. The prevalence of left ventricular hypertrophy, carotid intima-media thickening, plaques and microalbuminuria was significantly higher in patients with aortic root dilatation. According to a logistic regression analysis, left ventricular hypertrophy, carotid atherosclerosis, overweight and metabolic syndrome were the main independent and potentially modifiable predictors of aortic root dilatation in the whole hypertensive population as well as in untreated and treated hypertensive patients separately. CONCLUSIONS: Our study shows that hypertensive patients with aortic root enlargement have more pronounced alterations in cardiac structure and geometry as well as in carotid artery morphology compared with those without the enlargement. Aortic root dilatation therefore appears to be a useful marker of high cardiovascular risk related to TOD. Whether this alteration independently predicts cardiovascular morbidity remains to be proven.