Is there a relationship between left ventricular mass and plasma glucose and lipids independent of body mass index? Results of the Gubbio Study

BACKGROUND AND AIMS: The association between left ventricular (LV) mass (M) and variables described as features of the insulin resistance syndrome, such as obesity and measures o lipid and carbohydrate metabolisms, has been reported in hypertensives. The aim of the present study was to investigate in a large, population based group of non hypertensive people, the prevalence of LV hypertrophy (H) and the relationship of LVM with some of the variables described in the insulin resistance syndrome, independently of obesity. For this reason we investigated the normotensive subjects in the age range 45-54 yrs (n = 435) of the total population of participants in the Gubbio Population Study. METHODS AND RESULTS: Serum lipids, cholesterol (Chol), triglyceride (Tg), HDL cholesterol, fasting blood glucose (FBG), blood pressure (BP), body weight and height were measured and body mass index (BMI) was calculated; LVM was assessed by M-mode echocardiography. Using a normalization criterion not related to body weight (g/m2.7) and the cut-off of 49.2 g/m2.7 for men and 46.7 g/m2.7 for women, LVH was found in 25% of the sample whilst, when LVM was corrected by body surface area (cut-off 116 g/m2 for men and 104 g/m2 for women), the prevalence of LVH was quite lower (10.3%). In the univariate analyses LVMi was closely related to BP, BMI and metabolic variables whilst in the multivariate analysis only BP, BMI, and age were detected as independent predictors of LVMi. When the sample was divided into obese and non-obese subjects on the basis of BMI (cut-off 30 kg/m2), no difference in metabolic variables was seen between subjects with and without LVH within each BMI class. Regarding left ventricular geometry, RWT was positively related to triglycerides and blood glucose and inversely to HDL-chol. CONCLUSIONS: The present study in the middle age normotensive sample of the general population of Gubbio extends to normotensives the relationship between left ventricular mass and metabolic parameters already seen in hypertensives. BMI seems to account for most of the increases in LVM since the prevalence of LVH, which was definitely high when LVM was not normalized to body weight, fell to approximately 4% when the influence of body weight was excluded. Moreover differences in metabolic values between subjects with and without LVH disappeared when the subjects were stratified by BMI. Left ventricular geometry, on the other hand, seems to be related to some metabolic variables.     

Ethnic and gender differences in electrocardiographic QT length and QT dispersion in hypertensive subjects

BACKGROUND: Prolonged QT intervals and/or increased QT dispersion (QTd) are associated with various pathological conditions and predict death in healthy individuals. Among hypertensives, QTd correlates with blood pressure (BP) and left ventricular mass index (LVMI) and QT intervals are prolonged in those with left ventricular hypertrophy (LVH). In normotensives, heart-rate corrected QT length (QTc) is longer in females than males, but QTd is greater in males than females. There are few data comparing QT parameters between different ethnic groups and none specifically in hypertensives. Among normotensives, compared with whites, QTc is reported to be shorter in African-Americans and longer in Chinese. We looked for ethnic and gender differences in QT parameters in hypertensive subjects. METHODS: Untreated hypertensives were selected from a Hypertension Clinic database. Black and white subjects were matched for age, sex, BP and LVMI. Male and female subjects were matched for age, race, BP and the presence or absence of echocardiographic LVH. Maximum QT intervals (QTm), rate-corrected maximum QT intervals (QTc) and QT dispersion (QTd) were measured or calculated from ECGs. Data are presented as mean +/- s.d. Differences in QT parameters were sought between groups using Student's t-tests. RESULTS: No ethnic or gender differences in QT parameters achieved statistical significance. However there was a tendency for QTm and QTc to be prolonged in blacks compared with whites (443 +/- 52 vs 421 +/- 47; P = 0.08 and 480 +/- 65 vs 463 +/- 40: P = 0.24 respectively), and for QTc to be prolonged in females compared with males (479 +/- 52 vs 461 +/- 45 ms; P= 0.13). CONCLUSION: In small groups of matched hypertensives, no ethnic or gender differences in QT parameters achieved statistical significance. However, similar to findings in normotensives, QTc tended to be longer in hypertensive females than males. In hypertensives, we failed to confirm the finding that QTc is shorter in blacks than whites, as seen in US normotensives. Whether this represents a difference between hypertensives and normotensives, or between US and UK blacks requires further investigation. Whether the prognostic significance of QT parameters in hypertensives differs between different gender and ethnic groups needs to be established from prospective studies. Journal of Human Hypertension (2000) 14, 403-405     

Blood pressure on arising, morning blood pressure surge and blood pressure variability in white coat hypertensives and in matched normotensives and sustained hypertensives.

INTRODUCTION: It is still controversial whether subjects with white-coat hypertension (WCHT) exhibit higher cardiovascular risk compared to normotensive subjects (NT). In subjects with WCHT it is not known whether the abnormal blood pressure (BP) reaction in the office also occurs at other times of day, particularly on arising and immediately after waking, i.e. the times at which the majority of cardiovascular events are reported to occur. OBJECTIVE AND METHODS: To evaluate with 24h ambulatory BP measurement the values of morning BP surge, BP on arising and BP variability in subjects with WCHT in comparison with age-, gender- and weight-matched normotensives (BP) and untreated sustained hypertensives (BP). RESULTS: Groups of BP, WCHT and BP were matched for age, gender and body weight: BP: n=69, age 49 +/- 7 years, 54 % female, BMI 26 +/- 1, casual BP 126/79 +/- 5/4 mmHg, daytime BP 124/80 +/- 6/6 mmHg; WCHT: n=74, age 52 +/- 8 years, 57% female, BMI 26 +/- 2, casual BP 152/95 +/- 7/7 mmHg, daytime BP 126/80 +/- 5/6 mmHg; HT: n=79, age 53 +/- 7 years, 56% female, BMI 27 +/- 2, casual BP 154/97 +/- 9/8 mmHg, daytime BP 143/89 +/- 12/10 mmHg. Of the three groups, subjects with WCHT exhibited BP on arising (121/81 +/- 13/8 mmHg) similar to that of NTs (120/80 +/- 13/9 mmHg, NS), both significantly lower than that of HTs (137/92 +/- 17/10 mmHg, p < 0.01), suggesting the absence of an alerting BP reaction in WCHT at that time. By contrast, subjects with WCHT showed higher values of systolic morning BP surge vs. NTs (25 +/- 10 vs. 22 +/- 11 mmHg, p < 0.05), both lower than that observed in hypertensives (33 +/- 11 mmHg, p < 0.01 vs. NT and WCHT) and greater daytime variability (systolic BP standard variation), i.e. 12 2 vs. 10 +/- 2 mmHg, p < 0.05, both lower than that observed in hypertensives (14 +/- 3 mmHg, p < 0.01 vs. NT and WCHT). CONCLUSIONS: Although subjects with WCHT did not show any alerting blood pressure reaction on arising, morning BP surge and BP variability were greater in these subjects than in control normotensives, although lower than sustained hypertensives. Although this is still speculative, we cannot exclude the possibility that even a slight increase in morning BP surge might in the long term constitute an additional load on the circulation that could increase cardiovascular risk in subjects with WCHT compared to matched normotensives.     

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.     

Organ damage in treated middle-aged hypertensives compared to normotensives: results from a cross-sectional study in general practice

BACKGROUND: High blood pressure contributes to organ damage. However, during the past two decades there have been great advances in the medical treatment of hypertension. Technical progress has also made it easier to visualize organ damage. Hence we found it of interest to examine heart, brain and retina in a group of middle-aged treated hypertensives, comparing the results with those from a group of middle-aged normotensives. METHODS: The subjects were 40 (20 men) treated hypertensives and 40 (20 men) normotensives, who had previously taken part in a study in which ambulatory blood pressure monitoring had been performed. The heart was examined by echocardiography, the retina by photography and the brain by magnetic resonance imaging. RESULTS: Office blood pressure and 24-h systolic/diastolic blood pressure (S/D) were 141/86 (13/7) mmHg and 128/81 (11/6) mmHg in the hypertensives and 125/78 (10/8) mmHg and 118/74 (8/5) mmHg in the normotensives, respectively. Left ventricular mass was 101 (27) g/m2 in the hypertensives and 85 (18) g/m2 in the normotensives (p = 0.0025). The corresponding figures for the left atrium were 21.1 (3.1) mm/m2 in the hypertensives and 19.5 (2.2) mm/m2 in the normotensives (p < 0.001). E/A wave quotient was 1.09 (0.26) in the hypertensives and 1.26 (0.26) in the normotensives (p = 0.0045), while left ventricular systolic function did not differ between the groups. Ten hypertensives and one normotensive subject had left ventricular mass above normal range. Narrow retinal arteries were found in 22 hypertensives and 8 normotensives (p < 0.001). Brain magnetic resonance changes (deep white matter and/or periventricular) were found in 19 hypertensives and 9 normotensives (p = 0.0431). CONCLUSIONS: The hypertensives differed significantly from the normotensives concerning left ventricular mass, left atrium, left ventricular diastolic function and retinal vessel changes. Deep white matter and periventricular changes in the brain were also significantly different in the two groups. We can only speculate as to whether earlier antihypertensive treatment or further blood pressure reduction could have affected these differences.     

Cytosolic free calcium concentration in platelets in patients with renovascular hypertension and primary aldosteronism.

To investigate the role of cytosolic free calcium, [Ca2+]i, in secondary hypertension, the levels in platelets from 14 secondary hypertensives (7 renovascular hypertension, 7 primary aldosteronism) were compared with those from 21 essential hypertensives and 15 normotensives by means of the fluorescent indicator, quin-2. The mean BP was significantly higher in both the secondary hypertensives and essential hypertensives (122 +/- 8 and 124 +/- 12 mmHg) than in the normotensives (89 +/- 10 mmHg). Cytosolic free calcium in platelets was significantly higher in the essential hypertensives, but not in the secondary hypertensives, compared with the normotensives (182 +/- 34, 141 +/- 17, 138 +/- 15 nM respectively). There was no significant difference in platelet [Ca2+]i between renovascular hypertension and aldosteronism (142 +/- 19 versus 139 +/- 16 nM). There was no correlation between platelet [Ca2+]i and plasma renin activity, plasma aldosterone concentration or plasma noradrenaline concentration in the three groups. Thus, the increase in platelet [Ca2+]i seen in essential hypertension was not found in patients with secondary hypertension. Our results suggest that the cytosolic calcium handling of secondary hypertensive patients with renal artery stenosis or primary aldosteronism differs from that of essential hypertensives.     

Hemodynamics of elderly hypertensives

To study the hemodynamic characteristics of elderly hypertensives, elderly subjects (greater than or equal to 65 years old) were divided into normotensives (NT, n = 15), borderline hypertensives (BH, n = 10) and established hypertensives (EH, n = 20) and compared each group with similarly divided middle aged subjects (greater than or equal to 35 years old, less than 65 years old), NT (n = 23), BH (n = 112) and EH (n = 79). An attempt was also made to clarify what factor is most important regarding left ventricular hypertrophy (LVH) in elderly hypertensives. The results showed that with advancing age, cardiac output and stroke volume decrease (p less than 0.05), total peripheral resistance and volume-elasticity index increase (p less than 0.05), daily lability of systolic pressure increases and the baroreceptor slope increases. Furthermore, almost all of these tendencies are exacerbated by hypertension (p less than 0.05). With advancing age, pressure response to infused noradrenaline is enhanced (p less than 0.05), but on exercise, there are wide variations in each group and no distinct differences were observed. Echocardiographic examinations revealed LVH in 50% of elderly hypertensives. There were no apparent differences between both groups with or without LVH in their family and personal histories of hypertension, resting hemodynamics, hormonal examinations and hypertensive complications other than the heart. However, on exercise, the pressure response was more enhanced in the group with LVH than in the group without LVH (p less than 0.05). There was no significant correlation between resting systolic pressure (SBP) and left ventricular mass index (LVMi), but, there was relatively good correlation (r = 0.563, p less than 0.05) between SBP at peak exercise and LVMi. Using delta SBP/delta HR as a parameter of pressure responsibility on exercise test, 9 out of 10 patients with LVH showed above 1.0, while all of 10 patients without LVH showed under 1.0. Pressure response to infused noradrenaline seems to be more enhanced in the group with LVH than in the group without LVH. It was concluded that enhanced pressure responsiveness to recurring stress might induce or at least sustain LVH in hypertensives, due to enhanced alpha-adrenoceptor responsiveness.     

Ambulatory blood pressure in the young adult with hypertension history during childhood]

The tendency of subjects to maintain their relative position within the distribution of blood pressure (BP) has been defined as "tracking". Regarding this phenomenon, the purpose of the study was to evaluate the interest of ambulatory BP monitoring (ABPM) in the assessment of arterial hypertension in young adults (YA) with childhood hypertension history (CHH). 52 subjects, 20.1 +/- 2.4 years old, 26 men, 26 women issued from a cohort of 150 children with high BP levels (greater than 97.5 th percentile) during their infancy (school check-up), were included in the study. An ABPM was performed with space-labs system 90202 from 8 a.m. to 6 p.m., measurements every 15 minutes (37.6 +/- 7.4 readings). Left ventricular mass index (LVMI) was determined with echocardiography, (Penn convention). Office BP, measured with mercury apparatus in lying and standing position, was respectively, 131.0 +/- 14.6/81.9 +/- 9.7 and 130.1 +/- 14/86.6 +/- 9.9. According to JNC 1988, this casual BP identified 40 normotensives (NT), 9 borderlines (BL) and 5 hypertensives (HT); 10 of them had a "high normal" diastolic BP (85-90 mmHg) ABP recordings of the study group were compared to day-time reference values of NT. Three subgroups are individualized: G1 NT, G2 HT, G3 BL. [table; see text] *p: less than 0.001; p: less than 0.01. Wall thickness (WTh) and LVMI were significantly higher in hypertensives (G2 + G3) than in normotensives (G1): [table; see text] There was a significant correlation between LVMI and mean systolic ABP (p less than 0.01: r = 0.44), but not with office SBP.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ultrasonographic evaluation of cardiac and vascular hypertrophy in patients with essential hypertension]

High resolution ultrasonography allows the accurate and reproducible measurement of thickness and lumen diameter of carotid arteries. We investigated Common carotid (CCA) and bifurcation intima-media thickness in 40 hypertensive patients, 20 without left ventricular hypertrophy (LVH) (age 42 +/- 10 years) and 20 with LVH (age 44 +/- 12 years), all free from other important cardiovascular risk factors. Both carotid axes were scanned from different views (anterior, lateral, posterior) on traversal and longitudinal section, using a high resolution steerable (HRS) 5.0 MHz linear array. Carotid diameter and thickness from longitudinal section were measured. CCA parameters were taken 20 mm caudally to flow divider. Using the B-mode as a guide we assessed LVH presence with M-mode technique when left ventricular mass index (LVMI) > or = 135 g/m2 for men and > or = 110 g/m2 for women. In hypertensive patients with LVH, left ventricular mass was significantly higher than in those without LVH (156 +/- 38 vs 98 +/- 10 g/m2, p < 0.01). Even blood pressure was significantly higher in hypertrophic group (172 +/- 21/108 +/- 9 vs 158 +/- 11/99 +/- 12 mmHg, p < 0.01), while there was no difference in serum glycemia, triglycerides, total and fractioned cholesterol levels. The intima-media thickness scanned in both CCA and bifurcation resulted significantly higher in hypertensives with LVH (CCA: 0.85 +/- 0.02 mm vs 0.65 +/- 0.02 mm; BIF: 0.93 +/- 0.04 mm vs 0.70 +/- 0.03 mm, p < 0.01). We also noticed a statistically significant correlation between carotid wall thickness and left ventricular mass index.(ABSTRACT TRUNCATED AT 250 WORDS)     

Echocardiographic definition of left ventricular hypertrophy in the hypertensive: which method of indexation of left ventricular mass?

OBJECTIVES: It has been suggested that hypertensives at high risk of cardiovascular complications can be identified on the basis of their left ventricular mass as determined echographically. However, there is as yet a lack of consensus on the mode of indexation (body surface area, height, height 2.7) of left ventricular mass (LVM), and on the cut-off values for definition of left ventricular hypertrophy (LVH). The main objective of this study is to test the influence of the different modes of indexation for LVM on the prevalence of LVH in a population of never treated hypertensive patients on the basis of cut-offs for LVM based upon its relationship with ambulatory blood pressure (BP) measurement. METHODS: A population of 363 untreated hypertensives was investigated using a standardised procedure. The men and women were analysed separately. We studied the relationship between mean daytime ambulatory systolic BP and LVM and calculated the LVM cut-off for a BP of 135 mm Hg using three different methods of indexation. On the basis of these criteria, the population was divided into those with and those without LVH. RESULTS: The prevalence of LVH was found to be higher when LVM was indexed to height2.7 (50.4%) or height (50.1%). Prevalence was lowest when LVM was indexed to body surface area (48.2%), which tended to minimise the hypertrophy in obese individuals. Only indexation by height 2.7 fully compensates for relationships between height and ventricular mass in this population. CONCLUSIONS: Indexing LVM to height 2.7 thus appeared to give a more sensitive estimate of LVH by eliminating the influence of growth. Cut-offs of 47 g/m2.7 in women and 53 g/m2.7 in men corresponded to a cardiovascular risk indicated by a daytime systolic BP >/=135 mm Hg.     

Predictors of controlled ambulatory blood pressure in treated hypertensive patients with uncontrolled office blood pressure.

Although some treated hypertensive patients have controlled 24-h ambulatory blood pressure (ABP) despite their uncontrolled office blood pressure (BP), the factors relating to the control of 24-h ABP remain unknown. We conducted a study to assess 24-h ABP and its association with other cardiovascular risk factors, including echocardiographic left ventricular hypertrophy (LVH), in elderly hypertensive patients (n =41) with uncontrolled office BP (>140/90 mmHg) during long-term medication. Although a majority of the patients had isolated elevation of office systolic BP (SBP), there was no significant relationship between office SBP and 24-h SBP, and about half of the patients had controlled 24-h ABP (125+/-8/69+/-6 mmHg). Patients with controlled 24-h ABP (125+/-8/69+/-6 mmHg) had similar office BP (150+/-6/77+/-5 vs. 150+/-7/79+/-7 mmHg), but lower left ventricular mass index (LVMI) (123+/-34 vs. 156+/-34 g/m(2)) and body mass index (BMI) (24.4+/-2.1 vs. 26.4+/-3.6 kg/m(2)) compared with those with uncontrolled 24-h ABP (149+/-13/78+/-7 mmHg). Multivariate analysis showed that LVMI and BMI were independently associated with controlled 24-h ABP, and the control status of 24-h ABP was highly dependent on the presence of LVH and obesity. Therefore, absence of LVH and obesity may be useful for predicting the level of control of 24-h ABP in treated patients whose office BP is uncontrolled without ABP measurements.     

Left ventricular hypertrophy in treated hypertensive patients with good blood pressure control outside the clinic,but poor clinic blood pressure control

OBJECTIVE: The aim of the study was to evaluate the prevalence of left ventricular hypertrophy (LVH) in treated patients with good blood pressure (BP) control during multiple home BP (HBP) measurements and during 24-h ambulatory BP monitoring (ABPM), but with unsatisfactory BP control in the clinic. These patients were compared with treated hypertensives whose BP was well controlled under the three circumstances. METHODS: Seventy-two treated consecutive patients (group I, age 56 +/- 10 years) with clinic BP values > or = 140/90 mmHg, and a difference between clinic and self-measured HBP > 10 mmHg for diastolic blood pressure (DBP) and/or > 20 mmHg for systolic blood pressure (SBP), underwent the following procedures: (1) clinic BP measurement; (2) routine diagnostic work-up; (3) HBP monitoring; (4) 24-h ABPM; (5) echocardiography. Thirty-five hypertensive patients with satisfactory BP control according to clinic (< 140/90 mmHg), HBP (< or = 131/82 mmHg) and ABP criteria (< or = 125/79 mmHg) were included as the control group (group II, age 55 +/- 9 years). RESULTS: In group I, 33 subjects out of the 72 (46%) with clinic BP > 140/90 mmHg had BP values controlled outside the clinic (23 according to HBP criteria and 22 according to ABP criteria). The prevalence of LVH (LV mass index > 134 g/m2 in men and > 110 g/m2 in women) was significantly higher in these patients (15.1 versus 2.8%, P < 0.01) than in group II (BP also controlled in the clinic), despite the fact that HBP and ABP were reduced to similar levels in the two groups. CONCLUSIONS Our data provide evidence that treated hypertensive patients with good BP control at home or during ambulatory monitoring, but incomplete BP control in the clinic, have more pronounced cardiac alterations than patients with both clinic and out of the clinic BP control. This finding offers a new piece of information about the diagnostic value of BP measurement in the clinic to assess BP control during antihypertensive treatment.     

Impact of arterial elastance as a measure of vascular load on left ventricular geometry in hypertension.

OBJECTIVE: Effective arterial elastance (Ea), integrating the pulsatile component of left ventricular (LV) afterload, is an estimate of aortic input impedance. We evaluated relationships of Ea with left ventricular anatomy and function in essential hypertension. DESIGN: A cross-sectional analysis in 81 normotensive and 174 untreated hypertensive individuals enrolled in a referral hypertension centre. METHODS: Using echocardiography we determined left ventricular mass index (LVMI), relative wall thickness (RWT), stroke volume (SV), endocardial (FSe) and midwall (FSm) fractional shortening and total peripheral resistance (TPR). Carotid pressure waveforms were obtained by arterial tonometry, and end-systolic pressure (Pes) was measured at the dicrotic notch. Ea index (EaI) was calculated as Pes/(SV index); LV elastance (Ees) was estimated as Pes/LV end-systolic volume, and ventriculo-arterial coupling was evaluated by the Ea/Ees ratio. RESULTS: EaI was higher in hypertensives than in normotensives (3.02 +/- 0.63 versus 2.40 +/- 0.52 mmHg/l per m2; P< 0.0001). Using the 95% upper confidence limit in normotensives, hypertensives were divided in two groups with normal or elevated EaI. The 38 hypertensives with elevated EaI had higher RWT (0.41 +/- 0.06 versus 0.37 +/- 0.05), lower LVMI (87.5 +/- 18.5 versus 96.8 +/- 19.3 g/m2), higher TPR (2247 +/- 408 versus 1658 +/- 371 dynes/cm s(-5)) and lower FSe and FSm (35 +/- 5 versus 39 +/- 5 and 16 +/- 2 versus 18 +/- 2%; all P< 0.05) than patients with normal EaI. Ea/Ees ratio was increased and cardiac output was reduced in hypertensives with elevated EaI. CONCLUSIONS: High values of EaI identify a minority of hypertensive patients characterized by elevated TPR, left ventricular concentric remodelling, depressed left ventricular systolic function and impaired ventriculo-arterial coupling.     

Losartan controlled blood pressure and reduced left ventricular hypertrophy but did not alter arrhythmias in hypertensive men with preserved systolic function

The effect of antihypertensive therapy on arrhythmias is controversial. An initial study in patients with chronic heart failure indicated that losartan, an angiotensin II receptor antagonist, may possess antiarrhythmic properties. However, the effect of AT1 receptor antagonists on arrhythmias of subjects with good systolic function has never been evaluated. Thirty-nine men with primary hypertension (18 without left ventricular hypertrophy [LVH], and 21 with LVH, aged 48.2 +/-8.6 and 50.5 +/-6.0 years, respectively), 15 healthy normotensive subjects (47.9 +/-8.5 years), and 14 highly trained athletes (34.1 +/-1.6 years) were studied. Transthoracic echocardiography and 24-hour Holter ambulatory monitoring were performed at baseline (without treatment). Hypertensive patients underwent the same examinations after 8 months of losartan administration. The prevalence and complexity of ventricular arrhythmias, and the frequency of supraventricular arrhythmias were increased in hypertensive patients with LVH compared to normotensive controls and athletes, at baseline. A similar significant reduction of blood pressure (BP) was noted in both groups of patients (p < 0.001). The LVH was reduced in hypertensives with LVH (the left ventricular mass index by 12%, the interventricular septum by 8.1%, the posterior wall by 7%, all p < 0.01). However, the arrhythmias did not change in either group of patients, even if all hypertensives were considered as 1 group. In conclusion, an 8-month course with losartan was effective in lowering BP and reducing LVH. However, the increased arrhythmias, which were registered in hypertensive patients with LVH at baseline, did not change.     

Presence and severity of carotid atherosclerosis in asymptomatic hypertension patients with left ventricular hypertrophy]

BACKGROUND AND PURPOSE: Arterial hypertension is associated with structural changes in the cardiovascular system. In hypertensives, a relationship has been found between left ventricular hypertrophy and carotid wall thickness, whereas the association with atherosclerotic plaque is less defined. The aim of this study was to evaluate the occurrence and severity of carotid atherosclerosis in hypertensive patients with or without left ventricular hypertrophy (LVH). MATERIALS AND METHODS: We studied 122 hypertensive subjects (62 men and 60 women), aged 60.1 +/- 12.1. Subjects were considered to have left ventricular hypertrophy if their left ventricular mass index (LVMI) at echocardiography exceeded 110 g/m2 in women and 135 g/m2 in men. Carotid intima-media thickness (IMT), external diameter and atherosclerotic plaques were evaluated by high resolution echo-color Doppler. RESULTS: IMT in both common carotid and bifurcation was significantly greater in hypertensives with LVH (p < 0.01), whereas external diameter did not differ significantly in the two groups. Increased presence (73.4 vs 32.8%) and severity (18.7 vs 5.2% for stenosis > 40%) of atherosclerotic plaque were found in the hypertrophic group. A weak but significant association was present among left ventricular mass index, ventricular wall thicknesses and carotid intima-media thickness, and plaque. CONCLUSIONS: In asymptomatic hypertensive subjects, LVH is associated with an increased risk of plaque formation and progression. Vascular hypertrophy may represent a distinct prognostic factor in hypertension and the association of cardiac and vascular hypertrophy may identify a group at high risk of future cardiovascular events.     

Relationship between aortic stiffness and cardiovascular risk factors in a population of normotensives, white-coat normotensives, white-coat hypertensives, sustained hypertensives and diabetic patients.

OBJECTIVE: To evaluate the relationship between carotid-femoral pulse wave velocity (PWV) and office and ambulatory blood pressure (ABP) and other cardiovascular risk factors and to determine the discriminatory value of PWV in a large population including normotensive subjects (NT), white-coat normotensives (masked hypertension) (WCNT), and white-coat hypertensives (WCHT) compared to a group of treated and untreated hypertensive patients. METHODS: The study population included a total of 688 subjects aged from 18 to 80 years, with no previous cardiovascular events, who underwent 24 h ABP monitoring, biochemical evaluation and determination of PWV and left ventricular mass index (LVMI). Subjects were classified as true normotensives (NT, n=132; normal office and ABP values), WCNT (n=39; office BP < 140/90 and daytime BP > or =135 or > or =85 mmHg), WCHT (n=87; office BP > or =140 or > or =90 and daytime BP < 135/85 mmHg). Untreated (UT-HT, n=154) and treated (T-HT, n=171) hypertensive patients and type 2 diabetic patients (DM, n=102) were also studied. RESULTS: Values of PWV (m/s) in all groups were, in ascending order: NT (8.9 +/- 0.2) < WCHT (9.9 +/- 0.2) < T-HT (11.4 +/- 0.2) = WCNT (11.5 +/- 0.4) < UT-HT (11.9 +/- 0.3) < DM (12.6 +/- 0.4) (ANOVA, p = 0.043), and of LVMI (g/m2): NT (59 +/- 2) = WCHT (63 +/- 2) < WCNT (73 +/- 3) = T-HT (75 +/- 3) = UT-HT (77 +/- 3) < DM (84 +/- 4) (ANOVA, p < 0.05). The percentage of subjects with PWV values below the median (10.7 m/s) was higher (p < 0.02) in NT (81.8%) and WCHT (72.6%) than in UT-HT (49.2%), T-HT (43.6%), WCNT (47.6%) and DM (27.7%). In multiple regression analysis, taking PWV as the dependent variable, age (all groups), 24h systolic BP (UT-HT, T-HT, WCNT and DM) and 24h diastolic BP (NT and WCHT) were the variables that independently influenced the PWV value. CONCLUSIONS: Higher values of PWV occur in clinical situations associated with higher cardiovascular risk. This is in agreement with risk stratification based on ABP values but not on office BP values. Lower PWV and LVMI values occur in NT and WCHT subjects, supporting a low cardiovascular risk in these groups. By contrast, higher PWV values were associated with higher ABP values in DM, hypertensive patients and white-coat normotensives, i.e. clinical situations that are associated with higher cardiovascular risk, who in the present study also exhibited higher LVMI than subjects with normal ABP values.     

Twenty-four hour ambulatory blood pressure in a population of elderly men

OBJECTIVES: The principal aim was to study ambulatory and office blood pressure in a population of elderly men. We also wanted to describe the prevalence of hypertension and investigate the blood pressure control in treated elderly hypertensives. DESIGN: A cross-sectional study of a population of elderly men, conducted between 1991 and 1995. SUBJECTS: Seventy-year-old men (n = 1060), participants of a cohort study that began in 1970. MAIN OUTCOME MEASURES: Office and 24 h ambulatory blood pressure. RESULTS: Average 24 h blood pressure in the population was 133 +/- 16/75 +/- 8 mmHg, and daytime blood pressure 140 +/- 16/80 +/- 9 mmHg. Corresponding values in untreated subjects (n = 685) were 131 +/- 16/74 +/- 7 and 139 +/- 16/79 +/- 8, respectively. An office recording of 140/90 mmHg corresponded to an ambulatory pressure of 130/78 (24 h) and 137/83 mmHg (daytime) in untreated subjects. In subjects identified as normotensives according to office blood pressure (n = 270), the 95th percentiles of average 24 h and daytime blood pressures were 142/80 and 153/85 mmHg, respectively. The prevalence of hypertension, defined as office blood pressure greater than or = 140/90 mmHg, was 66%. Despite treatment, treated hypertensives (n = 285) showed higher office (157/89 vs. 127/76 mmHg) and 24 h ambulatory (138/78 vs. 122/71 mmHg) pressures than normotensives (P < 0.05). Fourteen per cent of the treated hypertensives had an office blood pressure < 140/90 mmHg. CONCLUSIONS: Our results provide a basis for 24 h ambulatory blood pressure reference values in elderly men. The study confirms previous findings of a high prevalence of hypertension at older age. It also indicates that blood pressure is inadequately controlled in elderly treated hypertensives.     

Clinical Implications of White Coat Hypertension

Objective: To determine the clinical implications of mild white coat hypertension (WCH).

Subjects and methods: We studied 102 subjects (54 men, 48 women). 51 of whom were normotensive and 51 slightly hypertensive. None had ever received antihypertensive therapy. An ambulatory blood pressure (ABP) record (Accutracker II), a 24-h electrocardiogram and an echocardiogram were obtained from each, and each was examined by funduscopy. WCH subjects were compared with sustained hypertension (SH) subjects and with normotensives.

Results: Fifty-three percent of the hypertensives qualified as WCH. The ultrasonographic characteristics and the ABP variables of the WCH group differed significantly from those of normotensives, but not from those of the SH group. The prevalence of left ventricilar hypertrophy (LVH) in the SH group (62.5%) did not differ significantly from its prevalence in the WCH group (40.7%). but the prevalence among normotensives (17.6%) was significantly lower than in either of the other two groups. The WCH and SH groups did not differ significantly as regards the prevalence of hypertensive retinopathy (33.3%) in the former, 58.3% in the latter). For no non-LVH, nonretinopathic subject, whether norniotensive or hypertensive, were more than 18% of daytime diastolic ABP measurements ≥90mmHg. Ultrasonographic findings were no better correlated with ABP than with in-clinic BP measurements. Fundus findings correlated well with in-clinic BP and with numerous ABP parameters. Retinopathy, with or without LVH, was efficiently predictable among hypertensives on the basis of body mass index and the 24-h maximum of systolic BP.

Conclusions: Myocardiac remodelling and vascular retinopathy develop early and in parallel in hypertensives, and both developments appear to involve determinants including body mass index and 24-h maximum systolic BP. WCH subjects, as defined by current ABP-based criteria, have cardiac and retinovascular Characteristics different to normotensive subjects. Stricter criteria are needed to discriminate between hypertensives with and without the systemic developments that constitute the immediate source of risk to the hypertensive individual.     

Isolated ambulatory hypertension and changes in target organ damage in treated hypertensive patients

Isolated ambulatory hypertension is a condition characterized by elevated ambulatory but normal clinic blood pressure (BP), and has been reported to be associated with increased cardiovascular risk in untreated subjects. However, little is known about the relationship between this condition and intermediate end points such as target organ damage (TOD) in treated hypertensives. We investigated the impact of isolated ambulatory hypertension on left ventricular hypertrophy (LVH) and microalbuminuria (MA) in a selected sample of treated nondiabetic hypertensives with effective and prolonged clinic BP control (BP<140/90 mmHg). Clinic BP measurements, routine diagnostic procedures, echocardiography and 24-h urine collection for MA, were undertaken in 80 patients (mean age 53+/-8 years) with essential hypertension attending our hospital outpatient centre at baseline and after an average follow-up of 30 months. At follow-up evaluation BP status was assessed by self-measurement of BP and ambulatory BP monitoring (ABPM). At the follow-up visit, 51 out of 80 patients (63.7%) reached a BP control according to ABP (average daytime BP<132/85 mmHg) criteria (group I) whereas the remaining 29 did not (group II); home BP was controlled (BP<135/85 mmHg) in all members of group I and in 86% of group II. In the overall study population, mean Sokolow voltage, LV mass index (LVMI) and urinary albumin excretion (UAE) decreased compared to baseline from 24.1+/-5.0 to 18.9+/-5.1 mm (P<0.05), 115.6+/-24.1 to 97.7+/-21.6 g/m(2) (P<0.01), 11.8+/-23.7 to 5.8+/-14.9 mg/24 h (P<0.05), respectively. The prevalence of ECG LVH, altered LV patterns and MA fell from 7.5 to 2.5% (P=NS), from 45 to 25 (P<0.01) and from 13.7 to 5.1% (P<0.05), respectively. However, when data were analysed separately for the two groups a significant decrease of echo LVH and MA was found only in patients with controlled ABP. LVMI and MA decreased from 117.1+/-23.1 to 95.9+/-22.1 g/m(2) (P<0.01) and 12.8+/-24.7 to 4.1+/-5.7 mg/24 h (P<0.05) in group I, and from 114.1+/-24.8 to 102.3+/-20.3 (P=NS) and 11.9+/-22.1 to 6.3+/-18.1 mg/24 h (P=NS) in group II. In conclusion, in the present study isolated ambulatory hypertension in treated patients is associated with a lack of regression in cardiac and extracardiac TOD, suggesting that a tight BP control throughout the 24 h plays a key role in lowering hypertension-induced structural and functional alterations at cardiac and renal level.     

Body composition and left ventricular geometry

Left ventricular mass and cardiac output are, particularly in obesity, correlated with fat free body mass. We assessed the relationship between ventricular geometry and fat body mass in treated hypertensives with or without normalization of blood pressure We investigated 175 patients (age: 57 +/- 15 years, M/F: 111/64, Mean blood pressure (MBP): 111 +/- 18 mmHg, BMI: 27.02 +/- 3.70 kg/m2: 20.3-39.6 kg/m2) with measure of body composition (impedancemetry Analycor2) and echographic left ventricular mass (adjusted to height2.7: mass2.7). Multiple correlation with adjustment to age and MBP were performed in men (M) and in women (W). Mass2.7 is correlated with fat mass percentage in men (R partial R: 5.6, p=0.02). LV diastolic diameter is correlated with fat free body mass while interventricular septum is correlated with fat body mass but only in men. In summary, in hypertensives not selected on BMI or BP, fat body mass is weakly correlated to ventricular wall thickness in men, probably mediated by sympathetic tone, while fat free body mass is related to ventricular volume in both gender probably through the water volume particularly in vascular bed. In conclusion, both components of body composition are differently, and weakly, linked to ventricular geometry in hypertensive patients.