Role of genetic variants in the gene encoding lipocalin-2 in the development of elevated blood pressure

Lipocalin-2 is recently recognized as a biomarker of obesity and inflammation, which are both risk factors for hypertension. We therefore investigated the association of common single nucleotide polymorphisms (SNPs) in the gene encoding lipocalin-2 (LCN2) with elevated blood pressure (BP) in Hong Kong Chinese. Five tagging SNPs were genotyped in 1936 subjects from the Hong Kong Cardiovascular Risk Factor Prevalence Study-2 (CRISPS-2) with a median follow-up time of 6.4 years. Elevated BP was defined as ≥130/85 mmHg or taking anti-hypertensive medication. Haplotype GGTCC was associated with elevated BP at follow-up after adjusting for age and sex (odds ratio (OR) [95% confidence interval (CI)] = 1.17 [1.01-1.36], P = 0.031). Haplotype GGTCC was also an associated plasma CRP level 11.7% (95% CI: 2.6-25.9%) higher among subjects with elevated BP after adjusting for age and sex (P = 0.036). Among 1381 subjects without elevated BP at baseline, 321 subjects developed elevated BP at follow-up. Haplotype GGTCC was associated with the development of elevated BP at follow-up after adjusting for baseline age, sex, systolic blood pressure (SBP), and follow-up duration (OR [95% CI] = 1.30 [1.06-1.58], P = 0.011). Among subjects not taking anti-hypertensive medication, carriers of the haplotype GGTCC had higher SBP than noncarriers (119.7 ± 16.4 mmHg vs. 117.9 ± 17.3 mmHg, P = 0.043). Our findings suggest, for the first time, that genetic variants in LCN2 may affect BP. Further studies on the role of lipocalin-2 in BP regulation are warranted.     

Relation of early and one-year outcome after acute myocardial infarction to systemic arterial blood pressure on admission.

We evaluated whether elevated blood pressure (BP) levels with an acute myocardial infarction (AMI) affect the in-hospital course, short-term, and 1-year outcome. Data were derived from a nationwide survey of 2,212 consecutive patients with AMI. Patients were stratified into 3 groups according to admission BP levels: 1,320 patients had normal BP, 840 patients had high BP, and 52 patients had excessive BP. In-hospital (7 days) course, short-term (30 days), and 1-year outcome was compared between the groups. The 3 groups were similar with respect to age, but patients with excessive BP were more likely to be women and have a history of systemic hypertension and diabetes mellitus. The rate of thrombolytic therapy was similar among the 3 groups, but patients with excessively elevated BP were treated during hospitalization much more often with beta blockers, angiotensin-converting enzyme inhibitors, and diuretics. The incidence of stroke, transient ischemic attack, and bleeding complications were comparable in the 3 groups. In-hospital mortality was 5.0% , 4.0%, and 1.9% in the normal, high, and excessively elevated BP groups, respectively (p = 0.19). The short-term rehospitalization or mortality rate was similar among the 3 groups. The 1-year mortality rate was 12.3%, 14.1%, and 10.2% in the normal, high, and excessively elevated BP groups, respectively (p = 0.61). A multivariate logistic regression analysis yielded age, women, and Killip class > or = 2 as the only significant predictors of mortality during follow-up. Thus, with the current medical therapy, excessively elevated BP levels with AMI is not associated with a worse short-term or 1-year outcome.     

Enhancing hypertension awareness and management in the elderly: lessons learned from the Airdrie Community Hypertension Awareness and Management Program (A-CHAMP)

BACKGROUND:

High blood pressure (BP) is an established and modifiable cardiovascular risk factor; however, awareness and management of this primarily asymptomatic disease remains suboptimal.

OBJECTIVES:

The Airdrie Community Hypertension Awareness and Management Program (A-CHAMP) was a community-based BP program for seniors designed to improve public and health care provider awareness and management of hypertension.

METHODS:

Volunteer peer health educators (VPHEs) were recruited from the community and trained to manage BP screening sessions in local pharmacies. Airdrie (Alberta) residents 65 years of age and older were invited by their family physicians (FPs) to attend the A-CHAMP sessions. VPHEs identified participants’ cardiovascular risk factors, assessed BP with a validated automated device and implemented a management algorithm. Participants with BP higher than 159/99 mmHg were directed to their pharmacists and FPs. All participants with elevated BP at the initial A-CHAMP session were invited to return to a follow-up session four to six months later.

RESULTS:

Thirty VPHEs were recruited and trained. All 15 FPs and all six pharmacies in Airdrie participated. VPHEs assessed 406 seniors (approximately 40% of Airdrie seniors) during the three-month program. One hundred forty-eight participants (36.5%) had elevated BP at their first session. Of these, 71% returned for the follow-up session four to six months later. The mean (± SD) systolic BP decreased by 16.9±17.2 mmHg (P<0.05, n=105) compared with their first visit, and 56% of participants (59 of 105) reached Canadian targets for BP.

CONCLUSIONS:

A-CHAMP raised awareness, and identified and managed seniors with hypertension. At follow-up, BP showed statistically and clinically significant and sustained improvement. Participating health care providers and VPHEs indicated that A-CHAMP was effective and feasible in improving awareness and control of hypertension.     

Albumin-to-creatinine ratio predicts change in ambulatory blood pressure in normotensive persons: a 7.5-year prospective study

BACKGROUND: The relationship between urinary albumin excretion and blood pressure (BP) has been found to be positive in hypertensive and normotensive subjects. It is not known, in a normotensive and nondiabetic sample, whether elevated urinary albumin levels predict future increases in BP. METHODS: In this prospective study, we followed a cohort of 108 individuals who were initially free of hypertension and diabetes for an average of 7.7 years. Urinary albumin excretion was determined at baseline by radioimmunoassay in a 24-h collection. Ambulatory BP monitoring was used to assess BP at baseline and at 7.5-year follow-up. Regression models were used to evaluate the relationship of baseline urinary albumin-to-creatinine ratio to baseline BP and average rate of change in BP before and after controlling for several potential confounding variables. RESULTS: Baseline albumin-to-creatinine ratio was not associated with baseline ambulatory BP, but was positively associated with change in ambulatory BP. Before and after controlling for sex, race/ethnicity, age, body mass index at baseline, and change in body mass index, urinary albumin-to-creatinine ratio was found to be a significant independent predictor of change in awake and sleep systolic and diastolic BPs (all P < .05). It also independently predicted hypertension status at follow-up. CONCLUSIONS: In healthy normotensive individuals, the urinary albumin-to-creatinine ratio predicts change in ambulatory BPs 7.5 years later. This finding suggests that urinary albumin excretion may be an important marker for processes that increase BP over time.     

Exaggerated blood pressure response to exercise--a new portent of masked hypertension

Masked hypertension (MHT) is a popular entity with increased risk of developing sustained hypertension, heart attack, stroke, and death. Subjects have normal blood pressure (BP) at office but elevated values at night so it is difficult to diagnose. Exaggerated blood pressure response to exercise (EBPR) is also a predictor of future hypertension. To investigate the relationship between these two entities, we evaluated 61 normotensive subjects with EBPR. The subjects underwent 24-h ambulatory blood pressure monitoring (ABPM). The prevalence of masked hypertension among subjects with EBPR was 41%. Body mass index (BMI), non-high density lipoprotein (HDL) cholesterol, diastolic blood pressure (DBP) at peak exercise and recovery, nondipping DBP pattern, and elevated early morning average BPs were associated with masked hypertension. In multivariate logistic regression analysis, the DBP measured at peak exercise was detected as an independent predictor of MHT in subjects with EBPR. Subjects with abnormally elevated BP during exercise are prone to MHT, necessitate medical assessment and close follow-up for hypertension.     

White-coat hypertension as a risk factor for the development of home hypertension: the Ohasama study

BACKGROUND: White-coat hypertension is a condition characterized by elevated blood pressure (BP) in medical settings combined with normal ambulatory-recorded BP or self-measured BP at home (home BP). However, it is unknown whether this condition represents a transient state in the development of hypertension outside medical settings. METHODS: We followed up 128 subjects with white-coat hypertension (home BP <135/85 mm Hg and office BP > or = 140/90 mm Hg) for 8 years and compared the risk of progression with home hypertension (home BP > or = 135/85 mm Hg or start of treatment with antihypertensive medication) with 649 sustained normotensive subjects (home BP <135/85 mm Hg and office BP <140/90 mm Hg) using data from population-based home BP measurement projects in Japan. RESULTS: During the 8-year follow-up period, 60 subjects (46.9%) with white-coat hypertension and 144 (22.2%) with sustained normotension progressed to home hypertension. The odds ratio of subjects with white-coat hypertension for progression to home hypertension (adjusted for possible confounding factors) was significantly higher than for subjects with sustained normotension (odds ratio, 2.86; P<.001). This association was observed independent of baseline home BP levels. CONCLUSION: The results from the present 8-year follow-up study demonstrate that white-coat hypertension is a transitional condition to hypertension outside medical settings, suggesting that white-coat hypertension may carry a poor cardiovascular prognosis.     

Interventricular septum thickness predicts future systolic hypertension in young healthy pilots.

Left ventricular hypertrophy (LVH) has been associated with hypertension, although debate exists as to whether LVH is caused by elevated blood pressure (BP) or is a risk factor for its development. The present study evaluates the association between left ventricular structure and the development of hypertension in a young healthy population. We followed young healthy Israeli Air Force aviators from initial echocardiography at the start of their military service to a mean of 7.5+/-3.0 years. Data collection included annual BP measurements, height, weight, smoking habits, and lipid profile. We monitored 500 Air Force men with a mean age of 20.5+/-3.3 (range, 17-40) years and baseline BP of 125+/-13/74+/-8 mmHg. Systolic BP during follow-up was associated with baseline systolic BP, interventricular septum (IVS) thickness, and ejection fraction, whereas diastolic BP was associated only with baseline diastolic BP and body mass index. The probability that the systolic BP during follow-up would be higher than the median was twice that in those with an IVS thickness greater than the median. In conclusion, IVS thickening was associated with long-term elevation of systolic BP. Therefore, it seems that IVS thickening is not merely a result of long-term BP elevation, but may predict the development of systolic hypertension.     

Audit of the treatment of arterial hypertension in specialized consultation]

The objective of the study was to estimate the control of elevated blood pressure (BP) among patients regularly followed-up and to analyse physicians attitudes in patients having uncontrolled BP. Two hundred and fifty-eight consecutive patients (mean age 56 years, 58% of males) with essential hypertension attending the outpatient department of a specialised hypertension clinic, having at least a 6-month follow-up at the clinic and at least 3 prior visits, were included in the study. Twelve different physicians were in charge of these patients. Data were collected [1] from the structured computerised record called ARTEMIS and [2] from a structured questionnaire filled up by the physician after each visit, where he/she explained the reasons for his/her decisions. BP was measured by a nurse using an automatic device (oscillometric method) and then by a physician using a mercury sphygmomanometer. During follow-up, mean physician's BP fell from 179/107 to 148/91 mmHg and mean nurse BP fell from 164/96 to 143/83 mmHg. Percentages of patients having a controlled hypertension (BP < 140/90 mmHg) were 27% (physician's BP) and 45% (nurse BP). Physicians did not modify treatment in 59% of patients among whom they measured a BP > or = 140/90 mmHg. The 3 main reasons given by physicians for not modifying treatment were: BP controlled when using other BP measurement methods (nurse, home or ambulatory BP), 44%; BP control considered as satisfactory, 29%; systolic hypertension in the elderly, 8%. The person (physician or nurse) who measures BP and the measurement method have dramatic consequences on BP control level. Reasons for not modifying treatment in uncontrolled patients (physician's BP > or = 140/90 mmHg) were based on opinions rather than evidence, for example when isolated systolic hypertension in the elderly is concerned.     

Exercise blood pressure in young adults as a predictor of future blood pressure: a 12-year follow-up of medical school graduates

It has not been fully clarified whether exercise blood pressure (BP) in young adult men and women is useful to predict future BP, especially in Asian people. A long-term prospective study was conducted in graduates of a medical school in Japan; 138 men and 76 women whose mean age was 19.8 and 19.2, respectively, at baseline. A 5-min exercise tolerance test was performed at baseline, and BP immediately after exercise was measured. BP at 50% intensity exercise was also calculated. Multiple regression analysis was carried out to clarify the relationship of exercise BP at baseline to follow-up BP after an average of 12 years. In multivariate-adjusted models, the relationship of systolic blood pressure (SBP) at follow-up was stronger to SBP immediately after exercise (F=7.7, P=0.006) than to resting SBP (F=3.7, P=0.055) in men. The models in men showed that SBP immediately after exercise was a stronger predictor of follow-up SBP than SBP at 50% intensity exercise, and the results were similar for diastolic blood pressure (DBP) in men. For SBP in women, resting SBP was the strongest predictor of follow-up SBP (F=14.3, P<0.001), and exercise SBP was not significant predictor. For DBP in women, any DBP at rest or after exercise was not significantly related to DBP at follow-up. In young adult men, SBP and DBP immediately after exercise would be a stronger predictor of future SBP and DBP rather than BP at rest. However, in young adult women, resting SBP rather than exercise SBP would be better to predict future SBP.     

Pediatric Hypertension: Are Pediatricians Following Guidelines?

The National Heart, Lung, and Blood Institute recommends that children older than 3 years seen in the medical setting have their blood pressure (BP) measured. The authors aimed to determine whether BPs are measured at well‐child visits and whether elevated readings are recognized. A retrospective chart review of 3‐ to 18‐year‐old children seen for well‐child visits was performed. Age, sex, weight, height, BP, extremity measured, and type of intervention were collected. BP was measured in 777 of 805 patients (97%). BP was elevated in 158 patients (20%). A total of 95 patients (60%) did not receive any intervention. Not recognizing elevated BP was associated with increased daily patient load (17.9±6.5 vs 12.6±5.5, P=.001). Higher body mass index was associated with elevated BP (P=.0008) but was not associated with improved recognition. Findings show that BP is almost always measured at well‐child visits but is not being measured appropriately, and general pediatric clinics are not consistently following BP management recommendations.     

Usefulness of cardiorespiratory fitness as a predictor of all-cause and cardiovascular disease mortality in men with systemic hypertension

There is an inverse gradient of mortality across levels of cardiorespiratory fitness in healthy adults; however, the association of fitness to mortality in persons with comorbidities such as hypertension is not fully understood. This study quantifies the relation of cardiorespiratory fitness to all-cause mortality and cardiovascular disease (CVD) mortality in hypertensive men. In this observational cohort study, we calculated death rates for low, moderate, and high fitness categories in normotensive (n = 15,726) and hypertensive (n = 3,184) men, and in men without a history of hypertension but with elevated blood pressure (BP) (systolic BP > or = 140 or diastolic BP > or = 90 mm Hg) at baseline (n = 3,257). The participants were 22,167 men (average age 42.6 +/- 9.2 years [mean +/- SD]) who underwent a medical examination that included a maximal exercise test during 1970 to 1993, with mortality follow-up to December 31, 1994. We identified 628 deaths (188 from CVD) during 224,173 man-years of observation. There was an inverse linear trend across fitness groups for all-cause and CVD mortality. The relative risk (95% confidence interval [CI]), using the low fitness group as reference, for all-cause mortality in hypertensive men was 0.45 (95% CI 0.31 to 0.65) and 0.42 (95% CI 0.27 to 0.66) for moderate and high fitness groups, respectively, and in men with elevated BP, 0.49 (95% CI 0.34 to 0.70) and 0.44 (95% CI 0.29 to 0.68) for moderate and high fitness groups, respectively. The pattern of results was similar for CVD mortality. There was an inverse linear relation between fitness and death rate for all-cause mortality in both the uncontrolled and controlled hypertensive groups. This study provides evidence that moderate to high levels of cardiorespiratory fitness provide protection against all-cause and CVD mortality in hypertensive men and men without a history of hypertension but with elevated BP at examination.     

Birth weight, hypertension and "white coat" hypertension: size at birth in relation to office and 24-h ambulatory blood pressure

We investigated the association of size at birth with hypertensive status defined by office blood pressure (BP) and 24-h ambulatory BP monitoring in a historical cohort study of 736 men born 1920-1924 and examined at age 70 years. Office BP was measured after 10-min supine rest with a sphygmomanometer, ambulatory BP was recorded with Accutracker 2, and anthropometric and other measurements were taken at a clinic. Birth weight and gestational age were abstracted from the men's birth records. A total of 24% of the men were treated for hypertension at the time of the study. Among not treated subjects, there was a weak positive association of birth weight with daytime and 24-h diastolic ambulatory BP. In subjects treated for hypertension, both office and ambulatory BP were inversely related to birth weight, although these associations were not statistically significant. Birth weight did not show significant association with sustained hypertension (elevated office and daytime ambulatory BPs) but showed a strong and statistically significant inverse association with "white coat" hypertension (elevated office BP and normal daytime ambulatory BP) when adjusted for concurrent body mass index (odds ratios 1.91, 1.59, 1 and 1.21 from lowest to highest quartile of birth weight, P-value for trend 0.035). We conclude that BP measured by 24-h-ambulatory monitoring is not related to birth weight in a pattern previously reported for office BP and that factors related to growth in utero are particularly related to higher risk of "white coat" hypertension.     

Psychosocial and physiological factors in relation to blood pressure at rest--a study of Swedish men in their upper twenties

The interrelationships between psychosocial factors, several physiological variables and blood pressure (BP) were investigated in 88 young men (aged 26-32 years) in whom high, intermediate or low BP had been recorded at the age of 18 years. In the original high BP group, venous plasma noradrenaline was normal but adrenaline levels elevated. At the follow-up adrenaline correlated with systolic blood pressure (SBP), and this was also so after controlling for overweight and serum gamma-glutamyltranspeptidase [gamma-GT, a marker for alcohol consumption, which showed an independent association with diastolic blood pressure (DBP)]. Low assertiveness (low scores of verbal and indirect aggression) correlated with high BPs, even after controlling for other psychosocial variables. Several associations between psychosocial job variables and physiological variables were found. Among self-reported job variables, excessive 'demands' and 'bossing others' (but not 'decision latitude' or 'psychosocial conflict') were associated with high SBP. Habitual smoking of cigarettes was not associated with BP at rest, but influenced several associations between psychosocial and physiological variables. Men with high BP at rest and low plasma renin activity (PRA) reported more psychosocial problems at work and lower assertiveness than other groups.     

Exaggerated Blood Pressure Response to Exercise – A New Portent of Masked Hypertension

Masked hypertension (MHT) is a popular entity with increased risk of developing sustained hypertension, heart attack, stroke, and death. Subjects have normal blood pressure (BP) at office but elevated values at night so it is difficult to diagnose. Exaggerated blood pressure response to exercise (EBPR) is also a predictor of future hypertension. To investigate the relationship between these two entities, we evaluated 61 normotensive subjects with EBPR. The subjects underwent 24-h ambulatory blood pressure monitoring (ABPM). The prevalence of masked hypertension among subjects with EBPR was 41%%. Body mass index (BMI), non-high density lipoprotein (HDL) cholesterol, diastolic blood pressure (DBP) at peak exercise and recovery, nondipping DBP pattern, and elevated early morning average BPs were associated with masked hypertension. In multivariate logistic regression analysis, the DBP measured at peak exercise was detected as an independent predictor of MHT in subjects with EBPR. Subjects with abnormally elevated BP during exercise are prone to MHT, necessitate medical assessment and close follow-up for hypertension.     

Psychophysiological correlations and reactivity of patients with hypertension

A clinical psychophysiologic and psychologic assessment was made twice, at 12 months' interval, in 203 patients with essential hypertension (EH). In addition to aggravated heredity, EH patients showing more marked BP increment under emotional stress had higher level of anxiety, rigidity and interpersonal conflicts. Different cardiovascular response to various emotive stressors was dependent on psychological characteristics of EH patients. EH patients with increased BP over follow-up period originally showed more marked diastolic BP response to emotional stress, and slower BP recovery after the exposure.     

Value of ambulatory intra-arterial blood pressure monitoring in the long-term prediction of left ventricular hypertrophy and carotid atherosclerosis in essential hypertension

The aim of this study was to compare the abilities of clinic and ambulatory blood pressure (BP) to predict the long term occurrence of left ventricular hypertrophy and carotid atherosclerosis in uncomplicated hypertensive patients. Two hundred and ninety-five patients who had undergone 24-h ambulatory intra-arterial BP monitoring on the basis of an elevated clinic BP, attended follow-up at a mean of 10.2 (+/- 3.5) years later. This consisted of a history, physical examination, risk factor profile and serum cholesterol level. Echocardiography and carotid ultrasonography were also performed to determine left ventricular mass index and maximal intima-media thickness (IMTmax), a measure of carotid atherosclerosis severity. The factors most strongly correlated with both left ventricular mass index and IMTmax were age, 24-h mean pulse pressure and 24-h mean systolic BP. Age, 24-h mean systolic BP and body mass index were independent correlates of left ventricular hypertrophy (R2 = 17%), whereas age, 24-h mean pulse pressure and pack years were independent predictors of carotid atherosclerosis (R2 = 34%). Clinic BP did not feature in the final model for the long term prediction of cardiovascular end-organ damage. These findings promote a role for ambulatory BP monitoring in guiding aggressiveness of drug therapy in an attempt to limit potential target organ damage.     

Heart rate as a predictor of development of sustained hypertension in subjects screened for stage 1 hypertension: the HARVEST Study

OBJECTIVE: Whether heart rate predicts the development of sustained hypertension in individuals with hypertension is not well known. We carried out a prospective study to investigate whether clinic and ambulatory heart rates assessed at baseline and changes in clinic heart rate during 6 months of follow-up were independent predictors of subsequent blood pressure (BP). METHODS: The study was conducted in a cohort of 1103 white, stage 1 hypertensive individuals from the HARVEST study, never treated for hypertension and followed-up for an average of 6.4 years. Data were adjusted for baseline BP, age, sex, body fatness, physical activity habits, parental hypertension, duration of hypertension, cigarette smoking, alcohol consumption, and change of body weight from baseline. RESULTS: Clinic heart rate and heart rate changes during the first 6 months of follow-up were independent predictors of subsequent systolic blood pressure (SBP) and diastolic blood pressure (DBP) regardless of initial BP and other confounders (all P < 0.01). A significant interaction was found between sex (male) and baseline resting heart rate on final SBP (P = 0.017) and DBP (P < 0.001). The ambulatory heart rate and the heart rate white-coat effect did not add prognostic information to that provided by the clinic heart rate. Patients whose heart rate was persistently elevated during the study had a doubled fully adjusted risk (95% confidence interval 1.4-2.9) of developing sustained hypertension in comparison with subjects with a normal heart rate. CONCLUSIONS: Baseline clinic heart rate and heart rate changes during the first few months of follow-up are independent predictors of the development of sustained hypertension in young persons screened for stage 1 hypertension.     

Treatment of renovascular hypertension using stent implantation in an elderly patient with NIDDM

A 70-year-old man with NIDDM was diagnosed as having renovascular hypertension (RVH), based on a stenosis of the ostial portion of the left renal artery with markedly elevated plasma renin activity (PRA) in both the left renal vein and the peripheral blood, and positive captopril tests. After percutaneous transluminal renal angioplasty (PTRA), his blood pressure (BP) and PRA normalized. However, since restenosis occurred three months later, stent therapy was applied, and consequently BP and PRA normalized immediately after this procedure. During the one-year follow-up, side effects have not been noted. We propose that stent therapy may be feasible for ostial renal artery stenosis in elderly diabetic patients.     

Reduced glomerular filtration rate and cardiovascular damage in diabetes: a key role for abnormal albuminuria

There is general agreement that a fall rate in glomerular filtration rate (GFR) is the principal endpoint in diabetics with renal disease, and that abnormal albuminuria (including microalbuminuria) is an important intermediate end-point. The relative roles of blood pressure (BP) elevation and abnormal albuminuria in the prediction and genesis of renal disease are a matter of debate, and are further analysed in this paper. New studies show that neither genetic predisposition to hypertension (parental BP) nor parental abnormal albuminuria can be used to predict renal disease in patients with type 1 (insulin-dependent) diabetes. However, parental predisposition to proteinuria seems to be important to certain types of patients with type 2 (non-insulin-dependent) diabetes. Cross-sectional as well as follow-up studies document that GFR is generally well preserved in microalbuminuria (in both type 1 and type 2 patients), while the transition to clinical proteinuria is associated with a decline in GFR. Thus, prevention of overt proteinuria is important in clinical trials in microalbuminuric patients. In type 1 diabetes clear ultrastructural changes have been documented with microalbuminuria and a good correlation between abnormal albuminuria and structural damage is seen. Structural damage in normo- and microalbuminuric patients correlates poorly with BP. New studies in type 1 diabetes document that microalbuminuria (but not elevated BP) predicts not only clinical diabetic nephropathy but also end-stage renal failure and mortality. In type 2 diabetes microalbuminuria is the strongest predictor of mortality, whereas BP elevation is not a predictor. Several studies now document that antihypertensive treatment, especially with inhibitors of angiotensin converting enzyme, is able to reverse or reduce abnormal albuminuria, even in non-hypertensive type 1 patients, and possibly preserve GFR. Therefore, microalbuminuria may be the main indicator for starting antihypertensive treatment in these patients. With respect to organ damage in the retina, abnormal albuminuria is an important indicator of the risk of severe diabetic retinopathy. BP elevation seems not to be an initiating factor, but rather aggravates established retinopathy. Left ventricular hypertrophy has a stronger correlation with BP elevation than normoalbuminuria, suggesting that left ventricular hypertrophy is at least partially a phenomenon secondary to elevated BP in diabetic patients with abnormal albuminuria. Generally, abnormal albuminuria is a strong indicator of cardiovascular renal damage in diabetic patients and in most organs is a stronger factor than elevated BP.