Marital cohesion and ambulatory blood pressure in early hypertension

One hundred thirty-four men and seventy-one women, unmedicated mild hypertensives, underwent 24-h ambulatory blood pressure (BP) monitoring (ABP) and completed standardized questionnaires measuring marital and job stress. Of these, 44.8% had daytime diastolic BP < 90 mm Hg; 96.1% had left ventricular mass index in the normal range (N = 176). Lower marital cohesion (Cohesion, subscale of the Dyadic Adjustment Scale) was related to elevated nighttime ABP (P ≤ .05) and 24-h diastolic BP (P < .05). With low Cohesion (N = 83), more reported spousal contact was associated with elevated nighttime ABP (P < .031). The 7.3% of subjects with very low Cohesion demonstrated approximately 6 mm Hg elevation of all ABP variables, controlling for other significant variables (P < .05, except for nighttime SBP). This study shows an association between marital cohesion and ABP and suggests that marital factors may have a role in sustaining BP in early hypertension.     

Ambulatory blood pressure and urinary albumin excretion in diabetic (non–insulin-dependent and insulin-dependent) hypertensive patients: Relationships at baseline and after treatment by the angiotensin converting enzyme inhibitor trandolapril

The aim of the present study was to examine the relationships between ambulatory blood pressure (ABPM) and urinary albumin excretion (UAE) in diabetic (non–insulin dependent [NIDDM] and insulin-dependent [IDDM]) hypertensives at baseline and after treatment by an angiotensin converting enzyme (ACE) inhibitor. After a 3-week placebo period, patients were treated for 16 weeks with trandolapril, 2 to 4 mg/day. The UAE and blood pressure (mercury sphygmomanometer and 24-h ABPM) were measured at baseline and repeated on trandolapril. Predictive factors of abnormal UAE (24-h UAE ≥30 mg) were determined using univariate and multivariate analysis (logistic regression). Predictors of UAE decrease were also searched. One hundred seventy-one patients entered the analysis. Baseline office BP was 164 ± 14/97 ± 6 mm Hg and 24-h BP was 142 ± 17/83 ± 10 mm Hg. Seventy-four patients (43%) had UAE ≥30 mg. Independent risk factors for abnormal UAE were nighttime diastolic BP (odds ratio [OR] = 4.1, confidence interval [CI] = 2.0 to 8.6, P = .0001), diabetes duration (OR = 2.4, CI = 1.1 to 5.0, P = .025), and presence of retinopathy (OR = 3.2, CI = 1.0 to 10.0, P = .047). Conversely, office BP level was not significantly related to UAE. On treatment, office BP levels decreased to 143 ± 13/82 ± 8 mm Hg (P < .0001) and 24-h BP levels to 134 ± 17/78 ± 9 mm Hg (P < .0001). In the abnormal UAE group, UAE significantly decreased from 76 to 50 mg/day (P = .006). After treatment, independent predictive factors of abnormal UAE were: on-drug fasting plasma glucose (OR = 3.5, CI = 1.7 to 7.4, P = .0009) and on-drug nighttime diastolic BP (OR = 3.5, CI = 1.7 to 7.4, P = .001). The only predictor of UAE decrease was a 24-h systolic BP decrease (OR = 2.3, CI = 1.3 to 4.3, P = .007). We conclude that in diabetic hypertensives with abnormal UAE, trandolapril exhibited a sustained 24-h antihypertensive effect and provided a consistent reduction of microalbuminuria. This study confirmed the superiority of ABPM over clinical BP to predict target organ damage.     

La presión arterial ambulatoria nocturna se asocia al remodelado auricular y la activación neurohormonal en pacientes con fibrilación auricular idiopática

Introduction and objectives

Hypertension is a risk factor for atrial fibrillation. Activation of the renin-angiotensin-system seems to be involved in atrial enlargement, with release of atrial and brain natriuretic peptides. The aim of this study was to evaluate the relationship between ambulatory blood pressure and levels of natriuretic peptides, with left atrial size in normotensives with idiopathic atrial fibrillation.

Methods

This was a cross-sectional study in patients with idiopathic atrial fibrillation. The following measurements were recorded during the course of the study: office and 24-h ambulatory blood pressure, atrial and brain natriuretic peptides, plasma renin, aldosterone, and angiotensin-converting enzyme.

Results

Forty-eight patients (mean age 55 [10] years; 70.6% male) were included in the study. Mean office sitting blood pressure values were 132.49 (14.9)/80.96 (9.2) mmHg. Mean 24-h ambulatory systolic and diastolic blood pressure values were 121.10 (8.3)/72.11 (6.8) mmHg (daytime, 126.8 [9.7]/77.58 [7.9] mmHg; nighttime, 114.56 [11.6]/68.6 [8.8] mmHg). A clear trend towards increased left atrial size with higher ambulatory blood pressure values was noted, which was statistically significant for nighttime values (r=0,34; P=.020 for systolic and r=0,51; P=.0001 for diastolic). A significant correlation between atrial natriuretic peptide and nighttime systolic (r=0,297; P=.047) and diastolic (r=0,312; P=.037) blood pressure was observed. Significant correlations were also observed between left atrial size and atrial natriuretic peptide levels (r=0,577; P<.0001) and brain natriuretic peptide levels (r=0,379; P=.012).

Conclusions

Nighttime blood pressure is associated with left atrial size and the release of natriuretic peptides in normotensive patients with idiopathic atrial fibrillation.Full English text available from:www.revespcardiol.org/en     

Lack of Association Between Blood Pressure Variability and Left Ventricular Mass in Essential Hypertension

Blood pressure (BP) variability could induce detrimental effects on left ventricular (LV) structure in hypertension. We investigated the association between short-term BP variability, assessed with 24-h noninvasive ambulatory BP monitoring, and LV mass at echocardiography in 1822 untreated subjects (953 men, 869 women) with essential hypertension (EH). The standard deviation (SD) of daytime and night-time systolic BP (SBP, r = 0.13/0.10; both P < .001), but not of diastolic BP, showed a weak correlation with LV mass. Because the SD of daytime SBP showed a direct association with average 24-h SBP (r = 0.27), subjects were ranked into quartiles of the distribution of 24-h SBP. For each quartile, the subjects with SD of daytime (and night-time) SBP below or above the median were classified at low or high BP variability. In both genders, subjects with high daytime SBP variability were older than those at low variability (both P < .01). Within each quartile, LV mass did not differ between the groups at low v those at high SBP variability. Overall, age-adjusted LV mass index was 115 and 115 g/m² in men at low and high daytime SBP variability (P = .84), and 116 and 114 g/m² in men at low and high nighttime SBP variability (P = .31). The corresponding values in women were 98 and 99 g/m² (P = .53) and 98 and 99 g/m² (P = .64). In conclusion, when the effects of age, gender, and average 24-h BP are taken into account, short-term BP variability assessed with noninvasive monitoring is unrelated to LV mass in subjects with EH.     

Blood Pressure and Heart Rate in Young Thalassemia Major Patients

The analysis of blood pressure (BP) and heart rate (HR) variability is currently used to investigate the mechanisms responsible for cardiovascular control; therefore, we assessed whether an impairment of 24-h BP and HR profiles and sympathovagal interaction modulating cardiovascular function was present in patients with thalassemia major (TM) in preclinical phase of heart disease. Nine β-thalassemic patients 18 years old without clinical signs of cardiac failure and 9 age- and sex-matched controls were studied. Twenty-four-hour-ambulatory BP and HR were measured using the SpaceLabs 90207 device. A truncated Fourier series with four harmonics was used to describe the diurnal blood pressure profile. Mean 24-h ambulatory systolic BP, diastolic BP, and mean arterial pressure were significantly lower in TM patients than in normal subjects (P < .05). A significantly higher nighttime HR value was found in TM patients (P < .05). More than 40% of the TM patients did not show a significant diurnal BP and HR rhythm. In TM patients, the overall amplitude of systolic BP, diastolic BP, and HR was significantly lower than in controls (P < .01). The night/day differences of systolic BP, diastolic BP, and HR were significantly lower in TM patients than in normals (P < .01). Furthermore, we performed power spectral analysis on short-term continuous finger BP and HR data in supine position and during passive head-up tilt. Total spectral power of systolic BP was significantly lower in patients than controls (P < .05). Low-frequency (LF) power of systolic BP and diastolic BP and LF/high-frequency (HF) ratio of HR were significantly lower during tilt in TM patients compared to controls (P < .05). High-frequency power of HR was significantly higher in patients than controls (P < .05). The baroreflex gain assessed by α-index was the same in supine position but was higher in TM patients during passive tilt (P < .05). An inverse relationship between LF/HF ratio of HR and hemoglobin levels in TM patients was found. Finally, plasma norepinephrine levels were significantly lower in thalassemics (P < .005). In young TM patients in a preclinical stage of heart disease, these findings demonstrated abnormal 24-h BP and HR rhythms and a decreased short-term variability of BP and HR, in particular in the LF range, showing a diminished sympathetic activity.     

Relación entre la presión arterial central y periférica con la masa ventricular izquierda en hipertensos

Introduction and objectives

The purpose of the present study was to assess the relationship of central and peripheral blood pressure to left ventricular mass.

Methods

Cross-sectional study that included 392 never treated hypertensive individuals. Measurement of office, 24-h ambulatory, and central blood pressure (obtained using applanation tonometry) and determination of left ventricular mass by echocardiography were performed in all patients.

Results

In a multiple regression analysis, with adjustment for age, gender and metabolic syndrome, 24-h blood pressure was more closely related to ventricular mass than the respective office and central blood pressures. Systolic blood pressures always exhibited a higher correlation than diastolic blood pressures in all 3 determinations. The correlation between left ventricular mass index and 24-h systolic blood pressure was higher than that of office (P<.002) or central systolic blood pressures (P<.002). Changes in 24-h systolic blood pressure caused the greatest variations in left ventricular mass index (P<.001).

Conclusions

In our population of untreated middle-aged hypertensive patients, left ventricular mass index is more closely related to 24-h ambulatory blood pressure than to office or central blood pressure. Central blood pressure does not enable us to better identify patients with left ventricular hypertrophy.Full English text available from:www.revespcardiol.org     

Relationship Between Left Ventricular Diastolic Function and Atrial Natriuretic Factor in Never-Treated Mild Hypertensives

Using digitized M-mode echocardiograms, we evaluated the relationship between plasma atrial natriuretic factor (ANF) and morphofunctional characteristics of the left ventricle (LV) in 24 mild hypertensive men, never treated, with normal renal function. For each subject we collected a blood sample for plasma ANF evaluation and, immediately after, we recorded the LV echocardiogram. All the patients had normal LV diastolic diameter and systolic function; LV hypertrophy was present in 10 patients, 7 of whom had left atrial enlargement, and 13 patients had impaired LV diastolic function. ANF was similar between patients with and without LV hypertrophy, as well as between patients with and without left atrial enlargement, whereas ANF was significantly (P < .01) higher in patients with LV diastolic dysfunction than in patients with normal diastolic function. ANF was inversely correlated with both indices of diastolic function (peak lengthening rate and peak wall thinning rate), whereas it did not correlate with blood pressure, heart rate, end-systolic wall stress, and other LV parameters. In conclusion, from our results, ANF level in never-treated mild hypertensives is related neither to the degree of LV hypertrophy nor to the afterload, expressed as blood pressure or end-systolic wall stress, whereas it is mainly influenced by LV diastolic function: the diastolic impairment induces an increase in ANF level, probably through an increased atrial stretch.     

Hypertension and arterial stiffness: the atherosclerosis risk in communities study

Our objective was to describe the relationship of arterial stiffness and hypertension in a large, population-based sample of men and women. Hypertension-related increases in arterial stiffness may reflect the distending pressure and/or structural alterations in the artery. Included were 10,712 participants, ages 45 to 64 years, of the Atherosclerosis Risk in Communities Study, free of prevalent cardiovascular disease. Hypertension was classified as systolic or diastolic blood pressure (BP) ≥140/90 mm Hg, respectively, or the current use of antihypertensive medications. Common carotid arterial diameter change was measured using B-mode ultrasound and an electronic device that utilized radio frequency signals to track the motion of the arterial walls.Using statistical models to control for diastolic BP and pulse pressure, arterial diameter change was calculated separately in normotensive/nonmedicated and medicated hypertensives. Hypertension was associated with a smaller adjusted diameter change (ie, greater stiffness) in comparison to optimal blood pressure (BP < 120/80 mm Hg): normotensive/nonmedicated men, 0.33 versus 0.43 mm (P < 0.001); medicated men, 0.34 versus 0.42 mm (P < 0.001); normotensive/ nonmedicated women, 0.34 versus 0.40 mm (P < 0.001), and medicated women, 0.33 versus 0.40 mm (P < 0.001). The relationship between pulse pressure and diameter change (ie, the slope of pulse pressure and diameter change) did not differ between hypertensives and normotensives.These cross-sectional data suggest that hypertension is associated with carotid arterial stiffness; however, these differences in the calculated stiffness appear to be the effect of distending pressure rather than structural changes in the carotid artery.     

Effects of potassium supplementation on office,home, and 24-h blood pressure in patients with essential hypertension

An increase in potassium (K) intake may lower blood pressure (BP), but inconsistent results have been obtained in clinical trials. We studied the effects of K supplementation in hypertensive patients with monitoring of home and ambulatory BP. Fifty-five patients with essential hypertension (26 men, 29 women, 36–77 years old) participated in this study. A 4-week K supplementation period and 4-week control period were assigned in a randomized crossover manner. During the K period, the subjects were given 64 mmol/day of K as slow-release KCl tablets. Office, home, and 24-h BP, as well as serum and urinary electrolytes, were measured at the end of each period. In the control period, office, home, and 24-h BP were 151 ± 2/88 ± 1 (mean ± SE), 138 ± 1/83 ± 1, and 137 ± 1/81 ± 1 mm Hg, respectively. Serum K increased from 4.15 ± 0.04 to 4.42 ± 0.05 mmol/L, and urinary K increased from 54 ± 2 to 96 ± 3 mmol/day with the K supplementation. Office, home, and 24-h BP were significantly lower in the K period than in the control period, although the differences were small (2.7 ± 1.1/1.4 ± 0.6, 3.6 ± 0.9/1.7 ± 0.5, 3.4 ± 1.0/1.2 ± 0.5 mm Hg, respectively). Changes in home and 24-h systolic BP with K supplementation were highly significant (P < .001), compared with office BP (P < .05). The change in 24-h systolic BP was correlated negatively with baseline BP and urinary Na/K ratio, and positively with baseline urinary K excretion. The changes in daytime and nighttime BP were comparable. These results indicate that increasing K intake lowers BP in hypertensive subjects, especially in those with higher BP and lower K intake. Our study supports the usefulness of K supplementation in the treatment of hypertension, although its antihypertensive effect may be small.     

Nocturnal systolic hypertension is a risk factor for cardiac damage in the untreated masked hypertensive patients

The nocturnal blood pressure (BP) has been identified as a prognostic factor for cardiovascular events. This study aimed to investigate the association between different patterns of nocturnal masked hypertension (MH) and the echocardiographic parameters in the untreated nocturnal MH patients. A total of 721 untreated MH patients (309 females and 412 males, mean age = 56.59 ± 15.20 years) from June 2006 and June 2016 were included and divided into nocturnal systolic MH (n = 77), nocturnal diastolic MH (n = 232), and nocturnal systolic/diastolic MH (n = 412) groups according to the ambulatory blood pressure monitoring. Baseline characteristics, office BP values, ambulatory BP monitoring parameters, and echocardiographic parameters were compared among the three groups. The independent factors associated with echocardiographic parameters were analyzed by multivariate linear regression. The nocturnal systolic group had the highest ratio of males, mean age, and office systolic BP (SBP), and the lowest office, 24‐hour, daytime, nocturnal diastolic BP and heart rate among the three groups. The nocturnal diastolic group had the lowest interventricular septum (IVS) thickness, left atrium (LA) dimension, and left ventricular (LV) mass among the three groups. Multivariate linear regression analysis revealed that 24‐hour, daytime, and nocturnal SBPs were all positively associated with LA dimension, IVS thickness, and LV mass (all B were positive and P < .050). Pearson's correlation analysis showed that nocturnal SBP was positively correlated with LA dimension, IVS thickness, and LV mass. These results suggested that different patterns of nocturnal MH had different echocardiographic outcomes. Nocturnal SBP was the independent factor associated with the echocardiographic parameters.     

Differential effects of morning and evening dosing of nisoldipine ER on circadian blood pressure and heart rate

The time of administration of once-daily antihypertensive agents may have a significant impact on blood pressure control during awake and sleep periods. Using 24-h ambulatory monitoring, we compared the effects of morning and evening dosing of the long-acting dihydropyridine calcium channel blocker, nisoldipine extended-release (ER), on circadian blood pressure (BP) and heart rate in patients with mild-to-moderate hypertension. After completing a 3-week placebo run-in period, 85 patients were randomized to morning versus evening nisoldipine ER treatment at a fixed 20-mg dose. Patients were treated for 4 weeks, followed by crossover to the alternate dosing regimen for 4 additional weeks. Twenty-four–hour ambulatory monitoring was performed at baseline and at 4 and 8 weeks after randomization. Awake and sleep times were determined by electronic activity recorders (Actigraphy). Similar least-squares (±SE) mean changes from baseline in 24-h BP (systolic BP/diastolic BP: −11.9/−7.4 ± 0.6/0.5 v −11.6/−6.5 ± 0.6/0.5 mm Hg) and heart rate (1.0/1.7 ± 0.4/0.4 beats/min) occurred with morning and evening administration, respectively. A significantly greater effect on awake diastolic BP (systolic BP/diastolic BP: −12.6/−8.1 ± 0.7/0.4 v −11.3/−6.4 ± 0.7/0.4 mm Hg; P = .16/.01) was observed with morning dosing compared with evening dosing. In addition, small increases in sleep and early morning heart rate were seen with evening compared with morning administration of nisoldipine (sleep, 3.1 ± 0.4 v 0.4 ± 0.4 beats/min; P < .001; early morning, 3.5 ± 0.7 v 0.5 ± 0.7 beats/min; P = .002). These differential effects on awake BP and sleep heart rate were also observed in patients who had normal (dippers) and elevated (nondippers) BP values during sleep. Appropriate evaluation of the efficacy and safety of long-acting antihypertensive agents is essential when evening administration is being considered. In the present study, the timing of nisoldipine ER administration had no effect on mean changes in BP and heart rate over a 24-h period. However, nisoldipine ER had some differential effects during sleep and awake periods with morning relative to evening dosing.     

Determinants of left ventricular mass in early hypertension

One hundred seventy-six unmedicated mildly hypertensive subjects (113 men, 63 women) underwent M-mode echocardiography to determine left ventricular mass (LVM) and relative wall thickness (RWT), 24-h ambulatory blood pressure monitoring, and completed standardized questionnaires measuring marital and job stress. Subjects were aged 46 ± 9 years old; 45.4% had daytime diastolic blood pressure < 90 mm Hg; 96.1% of LVM results were in the normal range. We found that neither marital distress nor job strain was a determinant of LVM. However, a segmental regression approach revealed inflection points of 131 mm Hg systolic daytime blood pressure and 83 and 87 mm Hg nighttime diastolic blood pressure in the relation between LVM and RWT, respectively, and ambulatory BP. In addition, we found that the variability of LVM was best explained by indexing LVM by height, rather than body surface area.     

Atrial Remodeling Following Catheter-Based Renal Denervation Occurs in a Blood Pressure– and Heart Rate–Independent Manner

ObjectivesThis study sought to investigate left atrial (LA) remodeling in relation to blood pressure (BP) and heart rate (HR) after renal sympathetic denervation (RDN).BackgroundIn addition to reducing BP and HR in certain patients with hypertension, RDN can decrease left ventricular (LV) mass and ameliorate LV diastolic dysfunction.MethodsBefore and 6 months after RDN, BP, HR, LV mass, left atrial volume index (LAVI), diastolic function (echocardiography), and premature atrial contractions (PAC) (Holter electrocardiogram) were assessed in 66 patients with resistant hypertension.ResultsRDN reduced office BP by 21.6 ± 3.0/10.1 ± 2.0 mm Hg (p < 0.001), and HR by 8.0 ± 1.3 beats/min (p < 0.001). At baseline, LA size correlated with LV mass, diastolic function, and pro-brain natriuretic peptide, but not with BP or HR. Six months after RDN, LAVI was reduced by 4.0 ± 0.7 ml/kg/m² (p < 0.001). LA size decrease was stronger when LAVI at baseline was higher. In contrast, the decrease in LAVI was not dependent on LV mass or diastolic function (E/E′ or E/A) at baseline. Furthermore, LAVI decreased without relation to decrease in systolic BP or HR. Additionally, occurrence of PAC (median of >153 PAC/24 h) was reduced (to 68 PAC/24 h) by RDN, independently of changes in LA size.ConclusionsIn patients with resistant hypertension, LA volume and occurrence of PAC decreased 6 months after RDN. This decrease was independent of BP and HR at baseline or the reduction in BP and HR reached by renal denervation. These data suggest that there is a direct, partly BP-independent effect of RDN on cardiac remodeling and occurrence of premature atrial contractions.     

Analysis of Factors that Affect Short-Term Blood Pressure Variability in Patients with Chronic Renal Failure

Recent reports suggest the relationship of short-term blood pressure (BP) variability to cardiovascular target organ damage. In this study, short-term BP variability was assessed as the standard deviation of daytime and nighttime BP in 36 hospitalized patients with chronic renal failure (CRF) who underwent ambulatory BP monitoring. Positive correlations were observed between body mass index (BMI) and daytime systolic and diastolic BP variability, BMI and nighttime diastolic BP variability, cholesterol and daytime systolic BP variability, cholesterol and nighttime systolic and diastolic BP variability, nocturnal decline in BP and nighttime diastolic BP variability, and plasma concentration of norepinephrine (p-NE) and nighttime systolic BP variability. In multivariate linear regression analyses, BMI showed the strongest association with daytime and nighttime diastolic BP variability (p < .005 and p < .05). On the other hand, cholesterol and p-NE were the primary determinants of daytime and nighttime systolic BP variability, respectively (p < .01 and p < .0005). Interestingly, CRF patients with ischemic heart disease (IHD) had significantly increased daytime systolic and diastolic BP variability and nighttime systolic BP variability (p < .05 or less). Furthermore, logistic regression analysis demonstrated that nighttime systolic BP variability was an independent risk factor of IHD in patients with CRF (odds ratio 1.50 [95% confidence interval 1.01 to 2.25]; p < .05). Taken together, short-term BP variability is suggested to be affected by BMI, cholesterol, and p-NE in CRF patients. Furthermore, sympathetic nerve overactivitymay be involved in cardiovascular complications in CRF patients through the increase in nighttime systolic BP variability.     

Factors influencing reduction in blood pressure and left ventricular mass in hypertensive type-1 diabetic patients using captopril or doxazosin for 6 months

The effect of doxazosin versus captopril on blood pressure, albuminuria, and left ventricular mass was studied in 33 hypertensive type-1 diabetic patients randomized to 6 months treatment with captopril (17 patients, mean daily dose 100 mg) or doxazosin (16 patients, mean daily dose 9 mg). Casual and 24-h ambulatory blood pressure (24hBP) were reduced from 163/95 to 144/83 mm Hg and 152/86 to 145/81 mm Hg, respectively, in the captopril group, and from 160/93 to 145/86 mm Hg and 156/86 to 147/79 mm Hg in the doxazosin group (all P < .05). The achieved 24hBP on treatment was positively associated with pretreatment levels of glycosylated hemoglobin (HbA_1c) and plasma atrial natriuretic peptide (r = 0.53 and 0.59, respectively, both P < .01). Albuminuria did not change significantly in either group. Left ventricular hypertrophy was present in 13 patients (7 in the captopril and 6 in the doxazosin group). Left ventricular mass was reduced by an average of 27% and 23%, respectively, in these patients (both P < .01), but did not change significantly in patients without left ventricular hypertrophy. The reduction in left ventricular mass was positively associated with the presence of baseline left ventricular hypertrophy and inversely with dietary sodium intake and achieved casual blood pressure on treatment (R² = 0.59, P < .001). We conclude that doxazosin and captopril used for 6 months are equally effective in reducing blood pressure and left ventricular hypertrophy in hypertensive type-1 diabetic patients; the antihypertensive effect is closely related to glycemic control; and dietary sodium intake and achieved casual blood pressure after treatment are independent determinants of the reduction in left ventricular mass seen in these patients.     

Diastolic function and tachycardia in hypertensive children

We investigated the prevalence and potential predictors of Doppler echocardiographic evidence of diastolic function in untreated hypertensive children. Doppler and M-mode echocardiographic values from 42 children (mean age 13, range 5–17 years) from a pediatric hypertension clinic were retrospectively reviewed and compared to data from 39 age and gender matched normotensive children in a control group. Compared to the participants in the control group, hypertensive patients had increased mean body mass index (29 v 19 kg/M², P < .0001), peak mitral A velocity (57 v 42 cm/sec, P < .0001), isovolumic relaxation time (65 v 42 msec, P < .0001, resting heart rate (90 v 74 bpm, P < .0001), mitral E deceleration time (150 v 137 msec, P = .006), indexed left ventricular mass index (32 v 26 g/M^2.7, P < .0001), relative left ventricular wall thickness (0.32 v 0.29, P = .02), and decreased ratio of peak mitral E velocity/peak mitral A velocity (1.7 v 2.1, P = .0001). Mean age, height, mitral E velocity, mitral A deceleration time, fractional shortening, and indexed left ventricular diastolic dimension were similar in patients and control group children. In the hypertensive patients, multivariate analysis demonstrated that heart rate (P = .0008) and systolic blood pressure (P = .03) were significant predictors of peak A velocity. In addition, heart rate (P = .0003), body mass index (P = .04), and indexed left ventricular diastolic dimension (P = .04) predicted the ratio of peak E/peak A velocity. None of the measures of diastolic function correlated with left ventricular mass index or relative wall thickness. Furthermore, none of the analyzed variables predicted isovolumic relaxation time or mitral E deceleration time. We conclude that untreated hypertensive children have Doppler indices suggestive of impaired left ventricular relaxation. Resting heart rate was the strongest predictor of abnormal diastolic indices.     

Microalbuminuria as a marker of preclinical diastolic dysfunction in never-treated essential hypertensives

Using 24-h ambulatory blood pressure (BP) monitoring and digitized M-mode echocardiography, we evaluated whether microalbuminuria is related to preclinical left ventricular (LV) diastolic dysfunction in hypertensive patients. We selected 87 never-treated hypertensive patients (mean 24-h BP > 140 and/or > 90 mm Hg); albuminuria was evaluated as mean value of 24-h urinary albumin excretion (UAE) from two 24-h urine collections. Microalbuminuria was found in 28 patients, classified as MA+ (UAE 30 to 300 mg/24 h); 59 patients had normal UAE (< 30 mg/24 h) and were classified as MA−. The MA+ and MA− groups did not differ with regard to age, sex, body mass index, or 24-h heart rate, whereas 24-h, daytime, and nighttime systolic and diastolic BP were significantly higher in MA+ than in MA−. The LV mass index was greater in MA+, as was the prevalence of LV hypertrophy; peak shortening rate of LV diameter, index of systolic function, was normal in all, but was lower in MA+. Peak lengthening rate of LV diameter and peak thinning rate of posterior wall, indices of diastolic function, were lower in MA+ and the prevalence of diastolic dysfunction was higher in MA+. UAE was inversely correlated with both indices of LV diastolic function, also after correction for age, 24-h heart rate, 24-h BP, and LV mass. In conclusion, in never-treated hypertensive patients, microalbuminuria is not only associated with greater myocardial mass, but is also related with preclinical impairment of LV diastolic function. This relation, independent from increased BP or LV mass, strengthens the role of microalbuminuria as an early and reliable marker of preclinical cardiac involvement.     

Rest and Effort Hemodynamic Responses During Prolonged Treatment With Felodipine, 24-h Blood Pressure Monitoring,and Echocardiographic Changes

In an open study, 16 patients with moderate essential hypertension were treated with 5 or 10 mg felodipine daily for 3 months. Hemodynamic (HD) indices were assessed at rest and during isometric effort (IE) at days 0, 3 to 7, 30, 60, and 90. Treatment efficacy was evaluated by ambulatory blood pressure monitoring for (ABPM) 24 h and divided between awake and sleep periods. Left ventricular mass (LVM) was determined before and at the end of treatment. Treatment normalized blood pressure (BP) in all patients (5 mg in 7 and 10 mg in 9). Systolic diastolic and mean arterial pressure (MAP) decreased significantly during the study (P < .01). The decrease in BP was significant on day 3 to 7 (P < .01) and tended to decrease further with treatment. Resting heart rate (HR) did not change. After 3 months systolic and diastolic pressureand MAP decreased significantly. Mean HR during ABPM differed between awake and sleep hours but did not change with treatment. When ABPM was divided into daytime and nighttime the awake BP decreased after 3 months (P < .01), but sleep measurements showed only a borderline decrease (P = .05). MAP after 3 months decreased in both awake and sleep periods. LV maximal and minimal dimensions did not change during treatment. Interventricular septum, posterior wall thickness, LVM, LVM/body surface area, and LVM/height tended to decrease, however this change was not significant. Hemodynamic measurements were measured at rest, at peak IE and posteffort. During treatment rest systemic vascular resistance (SVR) and MAP decreased, and there was no difference in ventricular ejection time, HR, and cardiac index. The increase in BP at IE was not prevented by treatment. After effort MAP decreased significantly and SVR tended to decrease in treated patients. Felodipine normalized resting BP in all patients. The main antihypertensive effect came at daytime and was less during sleep. No reflex tachycardia was seen during treatment. Echocardiographic measurements showed preservation of systolic and diastolic function and a tendency of decrease in LVM. Probably longer period of treatment is needed for clear-cut regression of LVM. Felodipine did not prevent the increase in BP and SVR during isometric effort, implying that normal cardiovascular reflexes are preserved during treatment.     

Clinical impact of dipping and nocturnal blood pressure patterns in newly diagnosed,never-treated patients with essential hypertension

The significance of nondipping and increased nighttime systolic blood pressure (SBP) in established hypertension is well defined. We investigated whether these factors alone or combined correlate with vascular damage in early-stage hypertension. Newly diagnosed, untreated hypertensives were classified as dippers and nondippers according to ambulatory blood pressure (BP). Twenty-four–hour urinary albumin excretion and markers of arterial stiffness (pulse wave velocity, augmentation index, central and peripheral pulse pressure, central BP) and atherosclerosis (carotid intima-media thickness) were assessed. Serum asymmetric dimethylarginine, an index of endothelial dysfunction, was measured in a study subgroup; 10-year cardiovascular risk was calculated. Among 222 hypertensives, only urinary albumin excretion was increased in nondippers, compared to dippers (P = .026). When dippers were further stratified according to nighttime SBP (<120 or ≥120 mm Hg), the first group demonstrated the lowest levels of office, aortic, 24-hour, daytime and nighttime BP, compared to dippers with elevated nighttime SBP and nondippers. Although vascular measurements and asymmetric dimethylarginine were comparable between these groups, dippers with normal nighttime SBP exhibited the lowest cardiovascular risk score (P = .050). In early-stage hypertension, nondipping was accompanied by microvascular, yet not macrovascular and endothelial dysfunction. Dippers with elevated nighttime SBP appear as a distinct group with increased hemodynamic pressure load and cardiovascular risk.     

Does Orthostatic Testing Have Any Role in the Evaluation of the Young Subject With Mild Hypertension?: An Insight From the HARVEST Study

The aim of the study was to assess the clinical significance of the blood pressure (BP) reaction to standing in 1029 stage I hypertensives. Office BP was measured six times in the supine position and six times after 2 min of standing. All subjects underwent 24-h ambulatory BP monitoring, and measurements of 24-h urinary epinephrine and norepinephrine excretion. Echocardiography was performed in 636 patients. With use of mixture analysis we could single out a population with abnormal diastolic BP response to standing (hyperreactors, n = 95). These subjects had a diastolic BP increase from lying to standing of >11 mm Hg. The other subjects were defined as normoreactors (n = 934). Office systolic BP was similar in the two groups. Diastolic BP was lower (91 ± 6 mm Hg v 95 ± 5 mm Hg, P < .0001) and heart rate was higher in the hyperreactors (77 ± 10 beats/min v 75 ± 9 beats/min, P = .004). After adjusting for age, gender, and smoking habits the statistical significance did not change. Adjusted 24-h systolic BP (P = .02) and diastolic BP (P = .02) were higher in the hyperreactors than in the normoreactors. Hyperreactors were characterized by higher cardiac index (3.2 ± 0.8 L/min/m² v 3.0 ± 0.7 L/min/m², P = .008 for adjusted values), lower total peripheral resistance (1420 ± 330 dyne/sec/cm⁻⁵ v 1600 ± 380 dyne/sec/cm⁻⁵, P = .003), and higher urinary norepinephrine output (114.9 ± 80.3 μg/24 h v 90.6 ± 78.5 μg/24 h, P = .03). Dimensional echocardiographic data and albumin excretion rate did not differ between the two groups. In conclusion, mixture analysis allowed us to identify a population of young mild hypertensives with exaggerated BP response to standing. Hyperreactors were characterized by higher whole-day BP and by a hyperkinetic hemodynamic pattern as a result of increased sympathetic tone.